Month: February 2022

General Practice in England: The Current Crisis, Opportunities and Challenges

General practice or family medicine has historically been lauded as the “jewel in the crown” of the English National Health Service (NHS). General practice, at the heart of primary care, has continued to contribute to the high ranking of the NHS in international comparisons and evidence from several decades of research has shown that general practice in the UK has improved the nation’s health. Furthermore, it has provided equitable, cost-effective, and accessible care for all with the flexibility to adapt rapidly to a changing society and political climates, such as during the COVID-19 pandemic when there was rapid implementation of remote consultation models. However, this much-admired public sector service has recently come under unprecedented political and media spotlight instigated by the pressures of the current pandemic on the NHS. This coupled with collapsing morale among general practitioners (GPs), a shrinking GP workforce, inexorable demands, increasing workload, and decreasing real-terms per capita funding have caused many to sound alarm on a general practice in “crisis”. In this article published in the Journal of Ambulatory Care Management, we describe the evolving nature of general practice and the current crisis, as well as potential solutions and opportunities going forward.

The full article can be read in the Journal of Ambulatory Care Management.

DOI: 10.1097/JAC.0000000000000410

Covid-19: Implications of ending the legal requirement to self isolate for employers and people who are clinically vulnerable

The government has just announced that all covid-19 restrictions in England are set to end. Boris Johnson, the UK prime minister, told MPs that he plans to remove the remaining restrictions, including the legal requirement to self isolate for people infected with covid-19. Instead of legislation, voluntary guidance will “advise” people with covid-19 not to attend workplaces. Employers will once again need to develop and implement new rules for their workplaces when the legal requirement to self isolate with covid-19 comes to an end. They should consider carefully how to develop and implement new policies fairly and safely in the workplace so that staff and customers—particularly those who are clinically vulnerable—are not put at risk.

Presenteeism occurs when employees go to work despite not being well enough to perform their duties. The NHS is the largest employer in England and the NHS Staff Survey showed a drop in presenteeism in 2020 compared to preceding years. This is likely an effect of covid-19, which forced workers and employers to endorse sick leave to prevent workplace outbreaks and has therefore gone some way to changing attitudes to calling in sick. Despite this, around 40% of NHS staff surveyed still reported coming to work in 2020, despite not being well enough to work.

Reasons why employees attend work while unwell include financial pressures. Statutory sick pay (currently £96.35 per week in England) is the minimum amount employers must pay to unwell employees; though not all workers are entitled to statutory sick pay—loopholes include agency work and zero hour contracts in certain situations. Though some workers are entitled to contractual sick pay which is closer to their normal salary, for many workers in England, taking sick leave means taking home less money; and sometimes no money at all.

Now that the legal requirement to self isolate will be scrapped, the government has announced that they will return to pre covid provisions of sick pay, with self isolation payments ending. Statutory sick pay and employment support will no longer be paid immediately, but only after four and seven days of absence. Workers who voluntarily decide to self isolate, but are unable to work from home, will in some cases face a loss in pay. The end to financial support for people to self isolate, or take sick leave, is concerning as people will no longer be financially supported to stay at home if they are ill. Those workers who are unable to work from home are more likely to be older, from lower socio-economic groups, and from ethnic minority backgrounds—factors that have cumulatively contributed to a higher occupational risk of death from covid-19 over the last two years.

The need for local health and safety policies will also leave employers with a dilemma. Should employers develop internal policies mandating self isolation for those infected with covid-19 to protect their workforce and their customers? The Health and Safety at Work Act 1974 places responsibility upon employers to ensure “as far as reasonably practicable” that both employees and non-employees are protected from workplace risks. The Equality Act 2010 mandates that employers make “reasonable adjustments” for employees with disability to protect them from workplace discrimination. For example, a retail assistant undergoing chemotherapy for cancer, for whom working from home is not possible, may be at high risk of acquiring covid-19 at work with significant medical complications now that the legislation mandating self isolation is going to be withdrawn. Who takes on the responsibility for this risk, and how can discrimination along the social gradient or against those with disability be avoided?

Presenteeism is not good for the individual attending work while unwell, nor is it good for the organisation. Covid-19, even when asymptomatic, brings risks of workplace outbreaks with significant impact on the operation of services due to sickness absences. Employers should consider workforce wide policies to encourage self isolation with fair pay when employees are infectious with covid-19, now that the legal mandate will be removed. Where this is not possible, individual occupational health risk assessments for employees vulnerable to severe covid-19 infection and its consequences should inform reasonable adjustments to their workplace duties. This will include, for example, examining how many people are allowed into the workplace at one time, ensuring good indoor ventilation, and mitigation measures such as high quality face masks are used as appropriate.

Employers will also need to consider factors such as the vaccination status of their staff and current community covid-19 infection rates in their health and safety policies. Most adults in the UK have now had two covid-19 vaccinations, but a large proportion (around one in three) have not yet come forward for a booster vaccine. Recent data show that the booster dose is essential in reducing the risk of serious illness, hospital admission, and death from a covid-19 infection caused by the omicron SARS-CoV-2 variant. Employers will need to work with their staff to promote covid-19 vaccination, but as the recent reversal in government policy for mandatory vaccination of healthcare workers shows, this is not straight forward. For the time being, community covid-19 rates are falling from the very high levels we saw in late 2021; and may remain at tolerable levels during the spring and summer of 2022. By next winter, however, we can expect a seasonal increase in respiratory viral infections, which will coincide with waning population immunity, placing more people at risk from covid-19.

Losing progress away from presenteeism will be a backwards step in all sectors of the economy as well as putting the most vulnerable members of society at greater risk. By ending mandatory self isolation while also removing financial support packages, the government is failing to adequately support people in lower paid occupations to protect themselves and others from covid-19, and risks widening existing socio-economic and health inequalities

Lara Shemtob, Kaveh Asanati and Azeem Majeed

A version of this article was first published in the British Medical Journal


Questions and Answers on the New Covid-19 Rules in England

If you only have mild symptoms how safe is it to go into an office or other workplace?

The question you should ask yourself is would you be comfortable being in the same office as someone who had a positive Covid-19 test the day before? Now that the legal requirement to isolate after a positive test in England is ending, employers will need to carry out risk assessments and implement their own infection control policies. My advice would be for employers to remain cautious for now and advise employees with symptoms or a positive Covid-19 test to stay off work for a period until we have more experience about the effect of the change in rules.

I’ve had plans to go for dinner and drinks with friends for a birthday party but have tested positive. If we’re all triple vaccinated how big a risk is it if I still go?

People who are fully vaccinated can still become infected. If you test positive for Covid-19, I would advise not attending the event, particularly if it is going to be in a crowded indoor venue where there is a significant risk of infecting others who are present. Although Covid-19 vaccination does substantially reduce the risk of serious illness and death, there is still a risk to older people and those who are clinically vulnerable even if they are fully vaccinated.

Will GPs and hospitals still only see you if you have no Covid symptoms?

If you have Covid-19 symptoms, you should inform your GP or hospital before they see you so they can take suitable precautions. We are still awaiting guidance for the NHS on how the new rules will operate for them, such as whether face masks will still be required in healthcare settings. However, because they deal with people who are clinically vulnerable, the NHS will need to take appropriate precautions to prevent someone with Covid-19 infecting other patients.

I was told to shield during the lockdowns, and now triple jabbed. Is it safe for me to go to places where people might have Covid?

If you are in a group that was advised to shield during lockdowns, Covid-19 still poses a risk to you even if you are fully vaccinated. You should continue to wear a well-fitting FFP2 mask in places like shops and on public transport. Whether you go to places with a higher risk of Covid-19 such as nightclubs is a personal decision that you need to take but I would advise being cautious until infection rates in the community fall further.

I work in a care home. What if I test positive, do I go into work as normal?

People living in care homes are at very high risk of a serious illness and death if they become infected for Covid-19. Care homes should therefore keep appropriate infection control measures in place, such as asking staff who test positive for Covid-19 to self-isolate for a period.

If everyone is going about normal life even if they have Covid, what’s likely to happen to infections and could it lead to herd immunity?

In recent weeks, the number of Covid-19 cases, hospital admissions and deaths have been falling. The high level of immunity in the population from vaccination and previous infection should keep the number of serious cases of Covid-19 at a manageable level. However, people’s immunity does decline over time, which is why the government has just announced that those at highest risk from Covid-19, people aged over 75 years and those with weak immune systems, will be offered another booster vaccination. The long-term future remains uncertain and we don’t yet know if an additional booster will be offered to a wider group of people later in the year. We also don’t know what will happen next winter when there may be a lower level of immunity in the population. Finally, there is always the risk that a more infectious variant of the coronavirus may emerge like the Omicron variant that we faced late in 2021. Unfortunately Covid-19 will remain with us for the foreseeable future and become part of our lives, like other respiratory infections such as flu.

These comments were first published in the Daily Mirror.

A national vaccination service for the NHS in England

The Health Secretary, Sajid Javid, announced on 26 January that a ‘national vaccination service’ is required to provide mass covid-19 vaccination to the population of England.[1] Speaking at a House of Commons Health and Social Care Committee meeting, Mr Javid suggested the proposed service could cover other vaccines as well as vaccines for covid-19. The rationale is that NHS General Practice is under great strain, and by removing some services that can be provided elsewhere, it will free up time for primary care teams to concentrate on their core work.

Traditionally, mass vaccine programmes in England have relied largely on general practices, increasingly supported by community pharmacies in recent years. This was demonstrated to great effect during the first wave of covid-19 vaccinations where the majority of vaccines were delivered by primary care teams. GP teams have secure electronic patient record systems, and are experienced in cold storage chains, and have medical support on site, including resuscitation equipment. Patients often know and trust their family doctors, and generally respond better to recalls for vaccination when these come from their own general practices. A move towards mass vaccine centres and away from primary care delivery may explain some of the recent slow-down in England’s covid-19 vaccine programme.[2]

The public need to be fully informed about what a national vaccination service will mean for them individually as well as the NHS. The majority of all NHS contacts occur in general practice, with around one million contacts per day.[3] This means that vaccines can be offered opportunistically when patients are attending for other reasons as well as in dedicated vaccine clinics. It also allows primary care teams to have discussions about vaccination during these consultations in patients who have concerns or questions about vaccines, or who are vaccine hesitant.

When attending for vaccination, patients also have the opportunity to discuss other issues in their health with their primary care team and to benefit from opportunistic health promotion. All this helps to ensure that vaccination is viewed holistically and not just as a transactional activity. This is particularly important for children where non-attendance for vaccination can sometimes be a safeguarding issue which requires a sensitive approach from primary care teams, as well as effective inter-agency working.

When the Prime Minister, Boris Johnson, announced that he wanted all adults England to be offered a covid-19 vaccine before the end of 2021 he looked to GPs to help. As a result, GPs were asked to drop all non-essential work and focus on vaccination for the remainder of the year. This caused much debate in the national and medical press about what the priorities should be for the NHS and for primary care. Suspending “non-essential work” will have adverse effects on people’s experience of the NHS and risks worsening health outcomes, particularly for poorer groups.[4] It is clearly also a policy that cannot be sustained for long or repeated frequently (for example, for another covid-19 vaccine booster programme later this year).

The current plan to consider a separate national vaccination service for covid-19 and possibly other vaccinations seems to be an effort to ensure that GPs are not asked to stop routine medical care again. Although investment in the NHS is welcome, and removing some workload from general practice might have merits, there are some caveats that must be considered before a new national vaccination service is established.

Firstly, any new vaccination service must be more cost-effective than existing models of delivery of vaccines, such as through general practices and pharmacists. At a time when NHS budgets are under great pressure, NHS funding must be used cost-effectively and services delivered efficiently. A new national vaccination service would require substantial funding to establish and run. For example, it is difficult to see how a national vaccine service could run effectively without full access to patients’ electronic medical records. It would also require premises from which to operate, and staff to manage and deliver the programme. We need the government to show how this investment in a new service would compare in terms of cost-effectiveness with a similar investment in primary care teams.

Secondly, a national vaccination service must achieve a high uptake of vaccination. We currently have very good uptake of most childhood vaccines in England and in 2021-22, primary care teams also achieved a record uptake of flu vaccines, for an extended group of patients compared to previous years. Vaccinations must also be delivered quickly and at scale when in a pandemic, and there must be a safe and robust system to target high risk groups; such as those with frailty, long term conditions, the housebound, people living in care homes, and patients from marginalised groups.[5]

Thirdly, creating a separate vaccination service risks further fragmentation of primary care. As we have already seen with the covid-19 NHS 119 service, many patients will still contact their GPs about vaccination queries, even if this is no longer part of the NHS GP contract. This risks creating extra work for primary care teams that is not part of their core contract and for which they will not be paid; and will also be very frustrating for patients who will have to deal with more than one healthcare provider to have any issues they have about their vaccinations and how these vaccinations are recorded are dealt with. Finally, a newly established national vaccine service may recruit staff from primary care teams, both clinical and non-clinical, thereby further worsening the current shortages of staff in NHS primary care.[6]

The government must therefore carefully examine the merits of a separate national vaccination service; and any problems it may cause for existing services; including how it might affect vaccine uptake. Investing in and strengthening existing NHS primary care infrastructure in general practices and pharmacies may be a more cost effective option. Because of the importance of vaccination in allowing England to move to “living with covid-19”, vaccinations programmes must be implemented well and achieve a high take-up, particularly in the groups most at risk of serious illness, complications and death from infectious diseases such as covid-19. We cannot risk undermining the current vaccination systems that already work efficiently and cost-effectively in England’s NHS. Any proposals for a new national vaccination service must therefore be assessed with the same rigour we would with any new medical treatment with serious consideration of the risks as well as the benefits.

 A version of this article was first published in the British Medical Journal.



  1. Health secretary proposes ‘national vaccination service’ to relieve GPs.
  2. Where are we with covid-19 vaccination in the United Kingdom?
  3. Appointments in General Practice.–weekly-mi/current
  4. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. Journal of the Royal Society of Medicine. 2020;113(6):208-210.
  5. Covid-19 vaccines: patients left confused over rollout of third primary doses.
  6. Oliver D. Act on workforce gaps, or the NHS will never recover BMJ 2022; 376:n3139