Month: October 2021

Why I don’t support GPs taking industrial action

I don’t support the BMA’s view that NHS GPs in England should consider taking industrial action. I think this will alienate the public and lose GPs support at a critical time. NHS England is not going to invest adequately in the current independent contractor model of general practice. Why does the BMA not ballot GPs about the NHS salaried option instead whereby GPs and their staff would become NHS employees?

The BMA’s GP Committee has always opposed the option of GPs becoming salaried employees of the NHS. For many years, NHS England has been unwilling to fully support the independent contractor model of NHS general practice. Instead, we are going to find the independent model gradually fading and GPs increasingly being employed by commercial companies contracted to deliver NHS services.

This will be a much worse outcome for GPs and patients than other alternatives. And in anticipation of all the responses from GPs about why the current independent model is better than salaried NHS employment, I know these arguments well and list them in a blog I published in 2013. I have been a GP partner for over 20 years and know how this model of NHS primary care works, including its strengths and weaknesses.

I make the counter argument about why we should pursue the option of GPs becoming salaried employees of the NHS (like the > 1m current NHS employees in the UK ) in an article I published in the BMJ in 2016. The BMA needs to consider this employment model seriously if it is to make working as a primary care doctor viable.

All the BMA’s attempts to prop up the independent contractor model of general practice in their negotiations and discussions with NHS England over the last 10 years have failed. Their latest attempt will also fail.

What can we do to reduce the risk of another lockdown this Winter?

We all want to avoid another lockdown. We need sustainable public health interventions that will keep Covid-19 cases, hospitalisations and deaths at an acceptable level, and get us through the winter. What could this mean in practice?

1. The most important public health intervention to control Covid-19 is our vaccination programme. This has slowed down in recent months. Also, in effect, it has split into four distinct programmes:

– a programme aimed at people 16 and over. This has almost stopped, with around 10% of adults in the UK still unvaccinated (higher in London).

– a third primary dose programme aimed at people with weak immune systems. This has been poorly planned and implemented by NHS England and has caused a lot of confusion.

– a booster dose programme. This is going OK but could be speeded up to provide more protection for key groups of people before the full onset of winter.

– a programme for 12-15 year olds. This has got off to a very slow start in England.

Speeding up all these vaccination programmes is essential and is our best defence against Covid-19.


2. Try to reduce social contacts; for example, by asking staff to work from home where possible. The government has been encouraging people to “get back into the office” but I think we should be cautious over the winter.


3. Face masks. The government needs to reconsider its policy. In my view, face masks should be required in settings such as shops and public transport.


4. Vaccine mandates / vaccine passports / negative test results. Many European countries require these for entry to higher risk settings such as nightclubs, bars and indoor events. No vaccine is 100% effective but the fact is that an unvaccinated person is much more likely to become infected and transmit infection to others than a vaccinated person. The government has flipped-flopped on this policy (currently against) but have said they may reconsider.


Effective measures now can help bring Covid-19 under control, protect public health, keep pressures on the NHS manageable, and get us through the Winter.

Setting up a Covid-19 vaccination programme for immunocompromised patients

On 1st September 2021 the JCVI  recommended that certain patients aged 12 and over, who were thought to be immuno-suppressed (through disease or medication) around the time of their first two doses of Covid-19 vaccine, should be offered a third primary dose 8 weeks after their second dose. There has been considerable confusion about these third primary doses as they are different from the booster doses that many people who are now over 6 months after their second dose are being offered. Many patients have reported they have been unable to obtain their third primary dose; or have only obtained after a lengthy dialogue with NHS clinicians and managers.

Here are the steps that could be followed to safely implement the third primary vaccine dose programme for immunocompromised patients in England’s NHS.

  1. Identify your target population. This is an essential first step in any vaccination programme (or in any public health programme). Identifying the target population requires searching NHS medical records held by hospitals and general practices.
  2. Clinical diagnoses (such as renal transplant) have to be turned into lists of clinical codes. This requires collaboration between hospital doctors, GPs, other health professionals and health informatics specialists to produce the code lists based on the ICD-10, SNOMED and Read clinical codes that are used by NHS organisations.
  3. Patients need to be identified who were prescribed medications around the time of their first two doses of Covid-19 vaccine that have been identified by the JCVI and specialist groups as possibly leading to a weaker response to their vaccinations. This might not be possible for GPs to do if they did not prescribe the medication themselves as is the case for many specialised drugs used for these patients.
  4. There needs to be adequate consultation with organisation such as NHS Digital, general practices, primary care networks, specialist medical societies, and patient organisations (for example, Versus Arthritis, Blood Cancer UK, Crohn’s & Colitis UK and Kidney Care UK amongst others).
  5. Once an agreed form of words and a unified approach have been reached, there should be a clear public health announcement via reputable sources, and NHS web pages available with clear easy to understand information and FAQs for clinicians, patient support organisations and the public. Clinicians and their teams should ideally be made aware of any announcements from NHS England before the public so that they are able to answer queries from patients, parents and carers.
  6. Those working at NHS 119, vaccine sites or the national covid-19 vaccine call centres must be fully briefed and updated on significant changes before any announcements are made, so that patients calling with queries or to book their Third Primary Doses are not met with a confused response and a lack of a clear process on how to access their vaccines (which damages public trust and confidence, and increases vaccine hesitancy).
  7. Programmes that use clinical codes to search NHS medical records have to be written. These require testing and debugging to make sure they work correctly on each different clinical record system used by the NHS. The NHS does not have a unified electronic medical record system and individual NHS Trusts and general practices will have different systems. These programmes need to be written centrally wherever possible to prevent local areas producing their own versions that may differ from each other and thus not identify patients correctly. This is more straightforward for general practices than hospitals because most general practices mainly use of one two electronic medical record systems (EMIS or SystmOne). The situation is more complex in NHS hospitals because of the many different IT systems used.
  8. Once the programmes are written, they need to be run by local NHS teams as it seems that NHS England is not yet able to run these searches centrally for all of England. In the case of general practices, local CCGs or GP Federations should be able to run the searches to identify patients. Hospitals will also need to run searches to identify eligible patients. The NHS should also make use of National Disease Registers, such as the NHS Blood and Transplant registry, for patient identification wherever possible.
  9. The list of patients generated by the programmes have to be cleaned to remove duplicates and any patients identified in error. Patients who may be unsuitable for vaccination such as the extremely frail or terminally ill need to be removed from the lists. Local NHS teams also need to consider how they approach patients who may have previously refused vaccination.
  10. Patients then need to be contacted about the vaccinations. Most general practices are no longer involved in the Covid-19 vaccination programme. These invitations therefore need to come from organisations that are offering Covid-19 vaccines. This might include hospital clinics, NHS vaccine centres, or GP-led vaccine hubs in areas where GPs are still offering Covid-19 vaccines.
  11. IT systems that record Covid-19 vaccinations (such as Pinnacle) need to be able to record the third primary dose correctly; so that it is not recorded as a standard booster dose or as another first or second dose. This ensures the patient’s vaccination status is accurate, that audits can be done accurately and that recalls can be generated for a booster in 6 months. Details of the vaccination also needs to be uploaded correctly into the patients’ usual electronic health record.
  12. The NHS app needs to correctly display that this is indeed a third primary dose, and that the patient is fully vaccinated; and IT systems need to ensure that the patients can then also be invited for their booster dose (effectively, a fourth vaccine dose for this special group of patients) in due course (typically likely to be six months after the third primary dose). A system for recording vaccines given abroad should also be made available.
  13. Please remember that in most parts of England, your general practice cannot offer you a Covid-19 vaccine or book you an appointment for one. In these circumstances, NHS 119 or your local NHS Covid-19 vaccine centre need to do this. To make access to vaccinations easier for patients, the NHS should ensure that a large number of locations are offering vaccinations so that patients can receive these close to home and do not have to travel long distances. Arrangements for vaccination also need to be made for the residents of care homes and for people who are housebound.
  14. NHS medical records are not always accurate or up to date. Each local area needs to have a named person who patients can contact if they feel they have been missed off the list incorrectly; or to help patients who continue to have any difficulties booking appointments.
  15. In order to provide a booster (fourth) dose for this group after six months, around April 2022, NHS IT systems need to be accurate and record third primary doses correctly and not as booster doses. This will ensure that this vulnerable group of patients do not experience further difficulties or delays in booking these appointments.

All these steps could have been better planned and communicated by NHS England; which would have made the process clearer for frontline NHS staff; as well as making it easier and less stressful for patients to receive their third primary Covid-19 vaccine dose. A well-planned and implemented vaccine programme maintains confidence in the vaccine programme which may reduce vaccine hesitancy, and helps patients and clinicians alike, improving vaccine uptake and reducing pressures on the NHS. It is essential that the problems experienced by immunocompromised patients in accessing their third primary Covid-19 vaccine doses are not repeated, appropriate lessons learned and steps taken by NHS England to ensure accurate recording of vaccinations and recall for future vaccinations for our most vulnerable patients.

Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, 

Simon Hodes, NHS GP Partner, Watford, UK and private general practitioner at the Cleveland Clinic London.

Fiona Loud, Policy Director, Kidney Care UK, Twitter

Liz Lightstone, Professor of Renal Medicine, Imperial College London, Twitter

This article was first published in BMJ Opinion.

Covid-19 vaccines: patients left confused over rollout of third primary doses

How a society treats its most vulnerable is always the measure of its humanity is a well-known quote often attributed to Mahatma Gandhi. With the “levelling up” agenda being quoted widely by the UK government, and the effects of pre-existing health inequalities never more exposed than by the covid-19 pandemic, we all need to focus on the health of the most vulnerable in society. Our highest risk patients, and their household members, were rightly prioritised for covid-19 vaccination at the start of the rollout programme in December 2020.

Early in the pandemic, the UK government recognised that certain patients with complex medical conditions, or who were immuno-suppressed through disease or medication, would be most at risk from the complications of covid-19. These patients were advised to take careful infection control precautions, and were classed as clinically extremely vulnerable” (CEV). Among the advice given to them was to “shield” and to facilitate this, they were added to a “Shielding Patients List” (SPL) at their GP practices. Despite GP practices having robust disease registers and arranging seasonal flu vaccine recalls annually for mostly similar patients, NHS England decided to create centrally generated lists for CEV, and sent out letters to these patients.

Unfortunately, NHS Digital wrote to many patients who probably should not have been included as CEV (for example those with a history of glandular fever; or with long resolved and fully treated cancers in full remission), and also failed to include many patients who should have been classed as CEV. At the time, a survey by Pulse reported that after assessing the list of shielded patients provided by NHS England, on average practices had to remove 30 patients from the list, while adding 53 patients who had been missed off.

GP teams nationwide spent many hours scrutinising these lists, using their electronic notes, disease registers, and personal patient knowledge. The list of CEV patients needed to be as accurate as possible to try to ensure that the most vulnerable were protected, pending the arrival of covid-19 vaccines.

The importance of the accuracy of these lists cannot be overemphasised. These patients were offered extra support from the government, and local volunteers such as regular check-up calls from social prescribers at GP practices and both the patients and their household members were prioritised for vaccines. The social and mental health impact of shielding has also been noted in practice and widely reported. When the Joint Committee on Vaccination and Immunisation (JCVI) announced the hierarchy of priority groups for vaccination, there was much debate about how high up the priority list CEV patients should be, with many surprised that they were left to be sixth in line, with priority for vaccination largely being determined by factors such as residential setting, health and social care occupation, and age.

We are now offering covid-19 vaccine boosters for many people who are over six months after their second dose. The JCVI also announced on 1 September 2021 that certain patients aged 12 and over, who were immuno-suppressed (through disease or medication) around the time of their first two doses, should be offered a third primary dose after eight weeks from their second dose. Once again, as seems to be a recurring theme throughout the pandemic, this process has been poorly announced with the media reporting it before healthcare professionals were instructed about the process; and without a clear plan for implementing the programme.

Our most vulnerable and naturally anxious patients are confused about who should be recalling them for a third primary dose, whether or not they will be given a booster (in effect their fourth vaccine) six months later, and where to access their vaccines. Kidney Care UK for example has been deluged with enquiries from patients, many of whom have tried calling the national NHS 119 helpline to find that the staff there are often unaware of the process for arranging third primary doses. Although the JCVI wrote to specialists on 2 September 2021, it clearly takes time to review notes, run searches, and contact patients, with many patients now contacting their GP practices for support and advice. Furthermore, many of these immune-suppressed patients may receive their medication from hospital clinics, and thus might not easily show up on medication searches in their general practices.

To add further complications, the software used (called Pinnacle) to record covid-19 vaccines is not yet able to recognise a third primary dose, so they are currently being recorded as boosters, which is technically not correct. This will make any audits of vaccine uptake in this group extremely challenging, and may cause confusion in the future. In addition, patients are reporting that their third primary doses are not displayed correctly on their NHS app, presumably for the same reason. Once again, this highlights the need for joined up thinking before rolling out plans. It is worth noting that GPs add seasonal flu vaccines on our fully electronic patient records (which are later uploaded to Pinnacle), but the covid vaccines have to be added on Pinnacle only (which is later uploaded to GP-held electronic medical records and the NHS app). This is the reverse of what we would expect and is once again an example of NHS staff being forced to adapt to IT systems rather than the IT systems being designed to support NHS staff in their day-to-day work.

The government must look at how they communicate with both the public and professionals to ensure that our ongoing covid-19 vaccination programme is fit for purpose, and maintains the trust of the public to ensure high take up and prevent vaccine hesitancy. Unfortunately, after a promising start, the UK has slipped down the covid-19 vaccination league tables, and we are becoming an international covid-19 hotspot because of our high infection rates. The covid-19 vaccination programme has allowed us to come out of lockdown, and its ongoing success will depend on public confidence and effective messaging from the centre. As we enter the winter, with many other non covid-19 seasonal infections already in circulation, it is crucial that we try to protect our most vulnerable in society by making our vaccination programme as easy as possible for patients to access and navigate.

Simon Hodes, GP Partner Watford, Twitter: @DrSimonHodes

Azeem Majeed, Professor of Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London. Twitter @Azeem_Majeed

This article was first published in BMJ Opinion.

Covid-19 treatments and vaccines must be evaluated in pregnancy

The numbers of pregnant and postpartum women in the UK admitted to hospital or intensive care because of Covid-19 peaked over the summer of 2021 Maternal mortality has reached concerning levels in 2021, with case fatality rates rising in the US, doubling in Brazil, and almost tripling in India since the beginning of the pandemic. In Brazil, health officials even suggested avoiding pregnancy to reduce risk during the pandemic.

Inconsistent messaging from authorities, driven by lack of trial data, has increased Covid-19 vaccine hesitancy among pregnant women. This, coupled with the increased transmissibility of new variants and relaxing of social distancing restrictions, contributed to the surge in hospital admissions seen in successive waves. Concerns around the longer term effect of Covid-19 post partum, including long Covid, cardiovascular complications of covid-19, and widening socioeconomic disparities are also mounting. Despite a desperate need for treatments, pregnant women continue to be left behind.

The full article can be read in the British Medical Journal.


Covid-19 vaccination in children, adolescents, and young adults: how can we ensure high vaccination uptake?

After a rapid start, the pace of the United Kingdom’s (UK) covid-19 vaccination programme has slowed down while the UK still faces high infection, hospitalisation, and death rates, and a more transmissible Delta SARS-CoV-2 variant. Now that vaccination of children aged 12-15 has started, it is essential to achieve a high uptake of vaccination in this group, and also in young adults, to both protect them and to move the UK closer towards population level immunity. [1,2] Despite two doses of Pfizer-BioNTech, Moderna, and AstraZeneca vaccines offering good protection against the Delta variant—with Pfizer-BioNTech and AstraZeneca vaccines between 92-96% effective in preventing hospitalisations—many young people remain unvaccinated by choice, raising their risk of infection, hospitalisation, and long-term complications from covid-19. [3-5]

The UK population is among the most willing to receive a covid-19 vaccine; as of 11 October 2021, over 49 million individuals (85.6% of people aged 16 and over) had received at least one dose of a covid-19 vaccine. [6,7] However, the covid-19 vaccination programme—the largest ever launched by the NHS—is reaching a “demand” ceiling in adolescents and young adults, finding itself well behind other Western European countries, and hampering efforts to achieve population level immunity. If vaccination uptake is also slow in 12-15 years old children, this will further hinder efforts to reach population immunity.

Vaccination rates in younger people are lower and increasing more slowly than was seen in older age groups when they were first offered vaccination. [1,8] According to the Office for National Statistics, 14% of those aged 16-17 years, 10% of those aged between 22-25 years, and 9% of those aged between 18-21 years consider themselves “hesitant” compared to 4% observed across all other age groups. [5] This mirrors concerning findings from the USA which demonstrate that one in four of those aged between 18 and 25 “probably will not” or “definitely will not” receive a covid-19 vaccine, despite their heightened infection risk in recent months. [9] Given their increased tendency to socialise, strategies that improve vaccine acceptance in adolescents and young adults remain essential to control the pandemic globally as well as in the UK. [10]

Historically, vaccine hesitancy exists on a spectrum and is listed by the WHO as one of the top 10 global health threats. [11] The groups that are among the currently most affected by the virus are also the ones with the lowest vaccination rates. [12] With ideal conditions for SARS-CoV-2 to spread, the risk of emergence of “super variants” that could potentially escape vaccines and jeopardise the health of the most vulnerable in society remains a risk. Vaccine hesitancy in young people in the UK may be further increased by the delay in approving vaccination for 12–15 year-olds, with the UK starting vaccination later than many other European and North American countries. The message from the UK’s Joint Committee on Vaccination and Immunisation (JCVI) that covid-19 vaccination in this group offers only “marginal benefits” will also have contributed to this, with many parents and children questioning why they should be vaccinated if this is the case. [13] The benefits and potential risk from vaccination will therefore need to be discussed carefully with children and their parents to dispel any unwarranted negative views. [14]

This has been successfully done in Portugal; despite Portuguese parents not being safe from vaccine misinformation and disinformation, the country has managed to emerge as the world’s vaccination front-runner, with 86% of its population vaccinated (98% of whom are aged 12 years and over). [15] Its successful vaccine rollout is, in part, attributed to the country’s comprehensive monitoring system; vaccine compliance is monitored nationally by healthcare facilities, schools, daycare centres, summer camps, and other child institutions, allowing the country to develop and tailor educational information to hesitant parents or parents known to have refused a vaccine in the past. [16] This has generated favourable conditions for paediatric immunisation across the country.

Concerns about side effects are an important factor in vaccine hesitancy in children, adolescents, and young adults, particularly the risk of condition such as myocarditis. [9] Although rare, the myocarditis and pericarditis reports in adolescents and young adults, following the administration of Pfizer-BioNTech and Moderna vaccines, will have amplified fears of vaccines in this group. [17] However, the risk of developing complications, such as blood clots and myocarditis, from covid-19 illness remains greater than the risk from vaccines. [18] Genuine concerns about the side effects of vaccines should be addressed by academics and clinicians proactively listening to young people, and sharing risks and benefits in a manner that aligns intention with action. [19] It is also essential that moving forwards, the UK’s covid-19 vaccination programme is embedded in primary care to create a cost-effective, sustainable infrastructure for vaccine delivery; and to avoid making the many mistakes that were made in other parts of the covid-19 response, such as Test and Trace and the Nightingale Hospitals. [20]

To offset optimistic bias, including adolescents and young adults perceiving the risk of disease being lower than the risk of receiving a covid-19 vaccine, communication should speak to mechanism of action, effectiveness, and safety relevant to these age groups and the wider societal benefits of vaccination in protecting their older family members, and vulnerable friends and colleagues. [10,21] Further, public health messaging will be more effective if the benefits of controlling the pandemic, including freedom to attend festivals, sporting events and entertainment venues, as well as the ability to travel are reinforced. Targeted health messaging and public education campaigns will also require harnessing social media, schools and universities to counter the covid-19 infodemic. [10] To increase vaccination rates, messages should be tailored for families financially burdened by the pandemic, families with lower parental education and incomes, and adolescents and young adults with adverse childhood experiences. [10]

While the risk of severe disease and death from covid-19 is lower in young people, high infection rates and low vaccination rates mean this group remains vulnerable to long covid and its debilitating symptoms, regardless of the symptoms shown during their covid-19 infection. [9] With the majority of covid-19 deaths occurring in those aged 75 years and over throughout the pandemic, a youthful sense of invincibility will be an important barrier to overcome; young adults need to be mindful that although their symptoms may not be as severe, 57%, 39% and 30% of individuals have stated that long covid has negatively impacted their wellbeing, ability to exercise and ability to work, respectively. [22,23] Recent evidence suggests more people expressed fear and concern about the risk to health of those close to them. [24] Therefore, emphasising the protection that vaccines offer to those particularly vulnerable will likely have a positive effect on adolescents and young adults and their parents.

The pandemic is a “collective action problem,” requiring personal responsibility and responsible communication by governments and public health authorities that break through optimistic bias without prompting feelings of anxiety. The UK’s mixed messages on mitigation measures including face masks and working from home are likely to provide a false sense of security that discourages vaccination uptake at a time when infection rates remain much higher in the UK than other European countries. The race between vaccinations and mutations requires consistent, clear, and data-based messages that dispel misinformation, and promote informed decision-making, civic awareness, voluntary cooperation and a sense of collective purpose. This will improve vaccine uptake in all sections of the population, including children, adolescents, and young adults, at a key time when vaccination is being extended in many countries to younger age groups.

Tasnime Osama, Honorary Clinical Research Fellow in Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London. Twitter @itasnimeo

Mohammad S Razai, NIHR In-Practice Fellow in Primary Care, Population Health Research Institute, St George’s University of London. Twitter @MohammadRazai

Azeem Majeed, Professor of Primary Care and Public Health, Department of Primary Care & Public Health, Imperial College London. Twitter @Azeem_Majeed

Competing Interests: None declared. 

Acknowledgements: AM is supported by the NIHR Applied Research Collaboration NW London. MSR is funded by the NIHR as an In-Practice Fellow. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

This article was first published by BMJ Opinion.


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Be aware of the overlap in symptoms between colds and Covid-19

During the previous winter (2020-21), rates of colds, flu and other respiratory infections were very low across the UK because of social distancing and other infection control measures. Now that these measures have largely stopped, we are seeing an increase in respiratory infections.

The symptoms of a cold can typically include a blocked or runny nose, sore throat, headache, cough , loss of smell, sneezing and muscle aches. Many of these symptoms can also occur in people with a Covid-19 infection. Now that most adults in the UK have been fully vaccinated with two doses of a Covid-19 vaccine, when people do contract Covid-19, it is often with milder symptoms that can overlap those from a cold. This means that for many people with these kinds of symptoms, a Covid-19 test will be needed to separate the two conditions.

There will be a lot of scope to confuse the symptoms of colds and Covid-19 during the winter. The message for the public should be to always be cautious if you have symptoms of a cold, get a test when appropriate, and limit interactions with people outside your household until you are better.

You can read more about this issue in this Daily Mirror article.