Author: Azeem Majeed

I am Professor of Primary Care and Public Health, and Head of the Department of Primary Care & Public Health at Imperial College London. I am also involved in postgraduate education and training in both general practice and public health, and I am the Course Director of the Imperial College Master of Public Health (MPH) programme.

London and South-East England Move to Tier 4 Restrictions

After a period from mid to late November in which the number of people with a positive Covid-19 test in the UK declined, in recent weeks we have unfortunately seen a rise in Covid-19 cases, with over 28,000 cases reported in the UK on 18 December. This rise in case numbers has been particularly high in parts of London and South-East England, leading today to these areas being placed into a new Tier 4 Level. Infection rates are also increasing in other parts of the UK, such as Wales, leading to increased pressure on the NHS.

Despite the enthusiasm and optimism generated by the Covid-19 vaccination programme, the number of people being vaccinated is well-below the level needed to start to reduce infection rates in the community. Without a very rapid escalation in the Covid-19 vaccination programme, which in turn depends on further vaccines being licensed for use in the UK and very quickly obtaining a much large supply of vaccines than we have available now, it will be sometime (perhaps several months, depending on vaccine availability) before enough people in England and elsewhere in the UK are vaccinated to have an impact on Covid-19 infection rates.

Our current crisis will require mass vaccination on a speed and scale we have not seen before in the UK. This needs to target older people, those with long-term health problems, and key workers in the first instance (NHS staff, care workers, and teachers for example); before moving on to other groups.

For the time being, it’s essential that people follow the local Covid-19 rules for the area where they live. In particular, mixing indoors with people from other households should be avoided as the risk of infection in substantially higher in crowded, indoor spaces where ventilation is poor.

Everyone should be mindful of older friends, relatives, and social contacts; and those with long-term medical problems. These groups are at the highest risk of serious illness and death if they contract Covid-19; and anybody in one of these groups should be very cautious in their interactions indoors with people not from their immediate household.

Although everyone wants to enjoy Christmas, it’s essential that infection control measures and local Covid-19 rules are followed during the holidays to protect yourself and others, and to relieve pressure on the NHS. Please also attend for your Covid-19 vaccination when you are invited. Achieving a high vaccine coverage rapidly is our best way to bring the Covid-19 pandemic under control.

Changes in Covid-19 Tiers in England

After a period from Mid-November onwards in which the number of people with a positive Covid-19 test in the UK declined, in recent days we have unfortunately seen a rise in Covid-19 cases, with over 25,000 cases reported in the UK on 16 December. This rise in case numbers has been particularly high in parts of London and South-East England, leading to more areas of England being placed in Tier 3.

Despite the enthusiasm and optimism generated by the Covid-19 vaccination programme, the number of people being vaccinated is well-below the level needed to start to reduce infection rates in the community. Without a very rapid escalation in the Covid-19 vaccination programme, which in turn depends on very quickly obtaining a much large supply of vaccines than we have available now, it will be sometime (perhaps several months, depending on vaccine availability) before enough people in England and elsewhere in the UK are vaccinated to have an impact on Covid-19 infection rates.

For the time being, therefore, it’s essential that people follow the local Covid-19 rules for the area where they live. In particular, mixing indoors with people from other households should be avoided as the risk of infection in substantially higher in crowded, indoor spaces where ventilation is poor.

Everyone should be mindful of older friends, relatives and social contacts; and those with long-term medical problems. These groups are at the highest risk of serious illness and death if they contract Covid-19 and should be very cautious in their interactions indoors with people not from their immediate household.

Although everyone wants to enjoy Christmas, it’s essential that infection control measures and local Covid-19 rules are followed during the holidays to protect yourself and others, and to relieve pressure on the NHS.

Measuring the long-term safety and efficacy of Covid-19 vaccines

The news that two UK recipients of the Covid-19 Pfizer-BioNTech mRNA vaccine suffered allergic reactions illustrates the need for accurate recording of any adverse events following administration of Covid-19 vaccines. As these vaccines are new, we don’t yet have long-term data on their safety and efficacy. This data is essential to help build public confidence in these vaccines and ensure take-up of the vaccines is high; not just in the UK but globally as well. The data will also help identify how frequently vaccination is needed to ensure vaccine recipients retain their immunity to Covid-19.

The UK is well-placed to collect this data. We have a National Health Service that has developed computerised medical records for use in general practices on a population of around 67 million people. These electronic medical records provide longitudinal data on people’s health and medical experiences. They can now also be linked to other data; such as hospital admissions records and mortality records, as well as to the results of Covid-19 tests, increasing their value for monitoring the safety and efficacy of the new Covid-19 vaccines.

The comprehensive nature of these medical records and the large population they cover mean that they can be used to look at safety and efficacy of Covid-19 vaccines in specific populations. This could be, for example, by age, sex, medical history or ethnic group. It would also be possible to look at more serious health outcomes and death rates by linkage to other data sets. Hence, planning how we would use these data is essential and needs to start now.

The use of these data will be facilitated by the recently developed clinical codes for Covid-19 vaccines for recording information in electronic medical records. These codes include, for example, codes for whether people attended or did not attend for their vaccination appointment; whether they declined to be vaccinated; and whether they had a clinical contra-indication to being vaccinated. Other codes allow recording of the specific vaccine that was administered, which will be essential for comparing the long-term safety and efficacy of different Covid-19 vaccines.

The data from electronic medical records can be supplemented by the reporting of any suspected adverse events by health professionals to the MHRA via the Yellow Card Scheme. Vaccine recipients should also be encouraged to report any reactions directly to the MHRA a well as to their doctor. This allows the MHRA to build up information on the safety profile of the new Covid-19 vaccines and advise patients and the public of any potential problems.

Curbing the spread of COVID-19 in low income countries

Globalisation impacts the epidemiology of communicable diseases, threatening human health and survival globally. The ability of coronaviruses to spread, quickly and quietly, was exhibited with Severe Acute Respiratory Syndrome in 2002–2003 and, more recently, with COVID-19. Not sparing any continent, the World Health Organization declared a COVID-19 pandemic on 11 March 2020. In an article published in the Journal of Royal Society of Medicine, we discussed how higher income countries can support the response to Covid-19 in low income countries.

Despite high-income countries being inordinately impacted, due to the increasing number of COVID-19 cases, SARS-CoV-2 continues to represent a looming threat to the Global South, leading the World Health Organization to previously state that ‘Our biggest concern continues to be the potential for COVID-19 to spread in countries with weaker health systems’ and that Africa could become the next epicentre.

However, while academics, public health experts and macroeconomists discuss among themselves, using collaborative strategies to reduce morbidity, mortality and economic devastation, these discussions have not involved low- and middle-income countries. COVID-19 may cause unprecedented humanitarian health needs in countries already subjected to unaffordable, fragmented and fragile health systems; as COVID-19 unfolds a worldwide economic crisis, with the poor and other vulnerable groups affected disproportionately, building health system resilience, through an urgent and coordinated global response, that allocates resources and funds efficiently, must be prioritised in this dynamic and shifting pandemic.

DOI: https://doi.org/10.1177/0141076820974994

Effectiveness of mental health workers colocated within primary care

Mental health disorders contribute significantly to the global burden of disease and lead to extensive strain on health systems. The integration of mental health workers into primary care has been proposed as one possible solution, but evidence of clinical and cost effectiveness of this approach is unclear. In a paper published in the journal BMJ Open, we reviewed the clinical and cost effectiveness of mental health workers colocated within primary care practices.

Fifteen studies from four countries were included. Mental health worker integration was associated with mental health benefits to varied populations, including minority groups and those with comorbid chronic diseases. The interventions were correlated with high patient satisfaction and increases in specialist mental health referrals among minority populations. However, there was insufficient evidence to suggest clinical outcomes were significantly different from usual general practitioner care.

We concluded that while there appear to be some benefits associated with mental health worker integration in primary care practices, we found insufficient evidence to conclude that an onsite primary care mental health worker is significantly more clinically or cost effective when compared with usual general practitioner care. There should therefore be an increased emphasis on generating new evidence from clinical trials to better understand the benefits and effectiveness of mental health workers colocated within primary care practices.

DOI: http://dx.doi.org/10.1136/bmjopen-2020-042052

The AstraZeneca adenoviral Covid-19 vaccine: What potential role does it have?

The results of the AstraZeneca adenoviral ChAdOx1 nCoV-190 vaccine trial published in the Lancet today are encouraging, even if the overall efficacy of 70% is lower than the 90-95% being reported for mRNA vaccines from Pfizer-BioNTech and Moderna; and from the Russian Sputnik adenoviral vector vaccine.

The AstraZeneca vaccine is cheaper than the mRNA vaccines and can be stored in a conventional vaccine fridge. Hence, it is an easier vaccine to use in primary care and community settings, including in low and middle income countries. The most commonly reported adverse reactions were fatigue, headache, feverishness, and myalgia. More serious adverse events were rare; none of which were thought to be due to either of the vaccines used in the study.

Based on these results, once the vaccine is approved by the MHRA, I would like to see it rapidly adopted by the NHS. The vaccine is highly suited for use in UK primary care as it can be stored in general practices and given to patients either opportunistically or in dedicated vaccination clinics. It can also be more easily used in care homes and for housebound patients than the mRNA vaccines.

There is ongoing research looking at vaccine combinations and if this research shows positive results, people may benefit from a second vaccine, such as an mRNA vaccine, after receiving an adenoviral vaccine. One caveat for all the Covid-19 vaccines is that we don’t yet know how long the immunity they generate will last. We also don’t yet know if they stop people being infectious.

Covid-19 vaccination – separating fact from fiction

Covid-19 vaccinations will kick off within days but it seems some people need a sharp dose of facts first. In an article published in the Daily Mirror, Matt Roper and I debunk some of the common myths and misconceptions about vaccines.

Scepticism about vaccines has been growing throughout the pandemic and a recent survey found that one in five British adults may refuse to take a coronavirus jab – even though it is probably our only hope of a return to normality.

  1. MYTH: A vaccine produced so quickly can’t be safe

Most vaccines take years to develop, test and approve for public use but, says Dr Majeed, a global effort has meant scientists have been able to work at record speed.

He says: “Covid-19 vaccines have to go through the same process of approval as other vaccines. Funding was made available immediately and studies set up rapidly.

“There have been a lot of technological developments that allow vaccines to be developed much more quickly.”

  1. MYTH: I might be allergic but won’t know until I get it

Azeem Majeed is professor of primary care and public health at Imperial College London

“Allergies to vaccines are very rare,” says Dr Majeed. “They are given safely to millions of people every year.”

The odds you’ll have a severe reaction to a vaccine is about one in 760,000.

Being struck by lightning next year is higher at one in 700,000.

Most reactions are because of some other component of the vaccine, such as egg protein, if the person is severely allergic.

3, MYTH: There haven’t been enough tests for people with underlying conditions

Dr Majeed says: “There are many vaccine trials taking place and they are being tested in people with different characteristics, such as age, sex, ethnicity and medical history.

“Results show they are safe in all groups they have been tested in.”

  1. MYTH: Vaccines can overload your immune system

In 2018 the myth was debunked by American researchers who examined the medical records of more than 900 infants from six hospitals.

 They found no link between vaccines given before the age of two and other infections in the following years.

 “Vaccines do not overload your immune system,” says Dr Majeed. “On the contrary, they generate an immune response that helps reduce the risk of infection, complications and death.”

  1. MYTH: The vaccine could actually give me coronavirus

Some vaccines contain the germs that cause the disease they are immunising against but they have been killed or weakened to the point they don’t make you sick.

In the case of a coronavirus vaccine, “none that are in development contain a live coronavirus,” assures Dr Majeed, “and they therefore can’t give you a coronavirus infection”.

  1. MYTH: If everyone around me is immune, I don’t need a vaccine

“It’s essential to achieve a high vaccine coverage so we create herd immunity,” says Dr Majeed. “If people refuse to be immunised, we will continue to get outbreaks of Covid-19.

“If you decline to be immunised, you may get infected and also infect the people you come into contact with.”

  1. MYTH: It’s better to be immunised by catching Covid

Dr Majeed says: “Vaccines have been shown to be very safe, whereas illnesses such as measles and Covid-19 can lead to serious long-term medical complications.

 “Vaccines have saved many lives and prevented people from being left disabled.”

  1. MYTH: Vaccinated children experience more allergic, autoimmune and respiratory diseases

This is another unfounded claim that has led some parents to delay or withhold vaccinations, says Dr Majeed.

 Studies examining many vaccines have failed to find a link with allergies or autoimmune disease.

 “Vaccines protect against many diseases and substantially reduce the risk of illness and death in children,” he says.

  1. MYTH: Some of those taking part in trials died

Stories that Dr Elisa Granato, one of the first participants in the human trials of the Oxford vaccine, died shortly after being injected, were shared millions of times.

 The news was false and she gave a BBC interview saying she was feeling “absolutely fine”.

 “Only one death has been reported among people taking part in trials,” says Dr Majeed.

 João Pedro Feitosa, a doctor in Brazil, was given the placebo rather than the vaccine and died of Covid-related complications.

  1. MYTH: The swine flu vaccine left people with side effects, so why would this one be safe?

A mass vaccination programme against swine flu in the US in 1976 led to increased chances of people developing Guillain-Barre syndrome, a rare neurological disorder.

 Dr Majeed says: “Covid-19 vaccines have been carefully tested in a large number of volunteers and found to be very safe.

 “Once they are more widely used, there will be monitoring of people who have received the vaccines to identify any future problems.”

  1. MYTH: Vaccines cause autism

 The idea that vaccines cause autism has long been disproved but the claims have recently been doing the rounds again.

 Last year a massive study from Denmark found no association between being vaccinated against measles, mumps and rubella, and developing autism.

 It is the latest of at least 12 other studies that have tried and failed to find a link.

 Dr Majeed says: “No evidence has ever been found that vaccines cause autism in children.”

  1. MYTH: The Spanish Flu vaccine led to 50 million deaths

During the 1918 pandemic it was the fact there was no vaccine that caused it to infect a third of the world’s population.

 In the 1930s scientists found it was caused by a virus, with the first vaccine developed a decade later.

Vaccinating the UK against Covid-19

The global Covid-19 pandemic has led to over 50,000 deaths in the United Kingdom, disrupted health services for many other conditions, and has had enormous economic impacts that have led to massive increases in unemployment and government debt.[1,2,3] With the United Kingdom’s failure to implement an effective test, trace and isolate programme as we have seen in countries such as South Korea and New Zealand, a vaccination programme offers us the best way to finally bring this pandemic under control[4]. It is therefore essential that the Covid-19 vaccination programme is implemented well and that we do not repeat the many mistakes we have seen in the government’s response to Covid-19, such as in the Test and Trace programme.[5]

Primary care should be at the heart of the delivery of the UK’s vaccine programme. With around 7,000 general practices in England, for example, they are easy for patients to access and their staff are generally well-trusted by the public.  Unfortunately, a decade of under-investment in primary care has led to a shortage of general practitioners, very overstretched primary care teams, and reduced the ability of primary care to respond to new challenges.[6] These problems cannot be addressed quickly but the government can take some immediate actions to reduce pressures on primary care. This could include, for example, cutting the administrative burden on general practices by suspending appraisals, revalidation and CQC inspections for the foreseeable future.

To ensure smooth implementation of the vaccine programme, funding is required to pay for new vaccination centres, provide current general practice clinics with the facilities they need such as equipment for transporting and storing vaccines, and meeting the costs of administering a complex vaccination regime to patients who are housebound or living in care homes. Other required measures include funding to rapidly recruit additional staff such as general practitioners, nurses, healthcare assistants to administer vaccines; and staff to provide administrative and management support. It is also essential that primary care services for the management of acute and long-term problems, and preventive programmes such as children’s immunisations, continue to operate normally. This means that additional capacity rapidly needs to be created in primary care so that the vaccination programme does displace or delay other essential clinical work, particularly as Covid-19 vaccines are likely to take longer to administer than the other vaccines currently offered by the NHS, resulting in considerable extra work for primary care teams.

Moving on to the logistics of vaccine delivery, there are currently two types vaccines that are close to approval in the UK. Adenoviral vector vaccines such as ChAdOx1 nCoV-19 are logistically easier to deliver as they can be stored long-term in standard vaccines fridges and so could be administered by primary care teams working in the patient’s usual general practice.[7] In Contrast, mRNA vaccines have to be stored at very low temperatures (minus 70 degrees Celsius for the Pfizer / BioNTech mRNA vaccine) and have to be used within a short period of time after defrosting.[8] Hence, mRNA vaccines are more suitable for large vaccination centres with a high throughput of patients rather than the typical general practice. In the longer term, as more data on safety and efficacy becomes available, it would be appropriate to focus on a smaller number of vaccines, rather than continue with the government’s current approach of having many different vaccine options. As well as simplifying the vaccination programme, this would also cut its costs and reduce the likelihood or patients missing out on their second dose of vaccine because of its unavailability or receiving the wrong vaccine at their second appointment.

Looking forwards, we do not yet know how long the immunity and protection from infection generated by vaccination will last.[9] People may therefore require booster doses of vaccine at regular intervals and the NHS should also plan for this. This requires good call-recall systems, something which general practices can provide because of their computerised medical records and experience of delivering other vaccine programmes. We also need observational studies to assess how frequently “vaccine failures” occur (i.e. how many people contract Covid-19 despite being immunised and what their characteristics are), as well as data on adverse events and safety. The UK, with its system of computerised primary care records, is well placed to generate this data, particularly if linkages can be made to other data such as hospital episode statistics and mortality records. To do this, the problems that afflicted the Test and Trace programme in its early days, such as the failure to record test results in primary care records, must be avoided.[10] This is could be successfully achieved by integrating vaccination recording at the time of vaccination administration in the patient’s primary care record and not creating a separate information technology infrastructure as was done with Test and Trace.[11]

We need to ensure the NHS, and in particular primary care, is well-prepared for the programme and that unrealistic expectations of the timescale are not created amongst the public. The Covid-19 vaccination programme is too important to the health, wellbeing and economic security of the UK to delay its implementation or to get wrong.[12] The government has invested considerable funding into other areas of the Covid-19 response, including funding the private sector to deliver services such as Track and Trace. The funding that has been allocated to the NHS for the vaccination programme is currently small in comparison. Whatever investment is needed for the successful and timely delivery of the vaccination programme should be promptly provided by the government so the programme can begin at scale, rapidly vaccinate the at-risk population of the UK, and finally allow life in the UK to start to return to normal.

This article is based on an editorial published in the British Medical Journal

DOI: https://doi.org/10.1136/bmj.m4654

References

1. 50,000 COVID-19 deaths and rising. How Britain failed to stop the second wave. https://uk.reuters.com/article/health-coronavirus-britain-newwave/special-report-50000-covid-19-deaths-and-rising-how-britain-failed-to-stop-the-second-wave-idUSL8N2I94SG

2. Maringe C, Spicer J, Morris M, Purushotham A, Nolte E, Sullivan R, Rachet B, Aggarwal A. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. The Lancet Oncology. 2020 Aug 1;21(8):1023-34.

3. Office for Budget Responsibility. Economic and fiscal outlook – November 2020. https://obr.uk/efo/economic-and-fiscal-outlook-november-2020/

4. Majeed A, Seo Y, Heo K, Lee D. Can the UK emulate the South Korean approach to covid-19? BMJ 2020; 369 :m2084.

5. Scally G, Jacobson B, Abbasi K. The UK’s public health response to covid-19 BMJ 2020; 369 :m1932

6. Majeed A. Shortage of general practitioners in the NHS BMJ 2017; 358 :j3191

7. Ramasamy MN, Minassian AM, Ewer KJ, Flaxman AL, Folegatti PM, Owens DR, Voysey M, Aley PK, Angus B, Babbage G, Belij-Rammerstorfer S et al. Safety and immunogenicity of ChAdOx1 nCoV-19 vaccine administered in a prime-boost regimen in young and old adults (COV002): a single-blind, randomised, controlled, phase 2/3 trial. The Lancet. 2020 Nov 19.

8. Bower E. Which COVID-19 vaccines are lined up for roll-out on the NHS? https://www.gponline.com/covid-19-vaccines-lined-roll-out-nhs/article/1700217

9. Centers for Disease Control and Prevention. Frequently Asked Questions about COVID-19 Vaccination. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html

10. Carrell S, Garside J. Coronavirus testing hit by struggle to match results with NHS records  https://www.theguardian.com/world/2020/may/28/coronavirus-testing-hit-struggle-match-results-with-nhs-records.

11. Lind S. GPs may need to record Covid vaccinations on separate IT system, says NHS England. https://www.pulsetoday.co.uk/news/technology/gps-may-need-to-record-covid-vaccinations-on-separate-it-system-says-nhs-england/

12. Iacobucci G. Covid vaccine: GPs need more clarity on logistics and planning, say leaders BMJ 2020; 371 :m4555.

Was the government right to announce an easing of Covid-19 restrictions during Christmas?

  1. Was the government right to announce an easing of Covid-19 restrictions during Christmas?

When the current lockdown in England ends, it’s likely the government will introduce a new system of tiered restrictions. My view is that these restrictions should remain in place through the Christmas and New Year period, based on the local community infection rate. Easing the restrictions too quickly risks undoing all the gains we have made during the lockdown. Greater social mixing indoors over the Christmas and New Year holidays will inevitably lead to an increase in Covid-19 infections.

 

  1. Could allowing mixing of households actually mean people will die as a result?

Most person to person transmission of Covid-19 infection occurs within households. This is the rationale for the government’s policy of stopping different households from mixing with each other indoors. Allowing mixing of households indoors will inevitably lead to an increase in infections, which would be very serious for more vulnerable people, such as the elderly and those with major medical problems, who are at greatest risk of serious illness and death if they contract Covid-19.

 

  1. Won’t locking down during January make up for the Christmas easing?

We need sustainable measures to control Covid-19 rather than “stop-start” measures.

 

  1. Isn’t Christmas too important for people’s mental health and well-being to deny them the chance to celebrate it as normal?

Christmas is a very important part of our social fabric. We need to think how we can allow people to celebrate without risking their health and the health of more vulnerable people.

 

  1. Can’t we trust people to still be responsible and limit contact with their elderly relatives even if restrictions are eased?

Most people will be mindful about the health of elderly relatives and will take precautions to prevent them from falling ill even if restrictions are eased.

 

  1. If restrictions stay in place, won’t there be more risk of people rebelling against the rules and wilfully disobeying them?

There is a risk of that some people won’t follow the rules but the vast majority of people will be sensible and follow the local restrictions that are in place. With positive news about developments in vaccines, we may be able to live much more normally from around Easter onwards. It’s important we retain our discipline and follow rules for these next few months until sufficient people have been vaccinated against Covid-19, allowing a degree of “herd immunity” to develop, which will lead to lower infection rates.

 

  1. Would there be any risks involved in opening up churches for Christmas services?

Any indoor mixing poses risks and activities such as singing in indoor spaces have been shown to lead to increased risks of infection. It may be possible though to open churches in some parts of England where local infection rates are low and where good infection control measures – such as physical distancing and restricting the numbers who can enter a church – are followed.

 

  1. Won’t elderly people be getting vaccinated before Christmas anyway?

Although we have had positive news about vaccines recently, no vaccine is yet currently licensed for use in the UK. Assuming a vaccine can be rapidly licensed and is available for use from December onwards, we won’t have enough doses of the vaccines to have a major impact on the pandemic in 2020. All the current vaccines we have heard about require two doses a few weeks apart. It’s only when a large proportion of people have been fully immunised with two doses of vaccine will we see the effect of vaccination and this is likely to take a few months to achieve.

 

  1. Even if they allow us to have a big family Christmas, should we?

I would be cautious about large, indoor Christmas events – particularly if you have elderly relatives or relatives with serious medical problems.

 

  1. I want my whole family together at Christmas. What can I do to reduce the risks? (Should we self-isolate 2 weeks before? Take the kids out of school earlier etc. Is there anything we can do inside the house to reduce risk?)

Self-isolation can help but does not entirely eliminate the risk of infection. It’s not a good idea to disrupt children’s education by taking them out of school. Actions to reduce the risk indoors include avoiding overcrowding so that physical distancing can be maintained, ensuring that ventilation is good as the risk of infection is much higher in poorly ventilated spaces, and practising good hygiene, such as regular handwashing.

 

  1. Should we still get together for Christmas if the households have to travel from different parts of the UK to meet up?

It’s better to “stay local” if you can for Christmas. Once a vaccination programme is in place, this will allow a return to a more normal society; resulting in a much better Christmas experience for everyone next year in 2021.

Characteristics of children who are frequent users of emergency departments in England

Increasing pressures on emergency departments present a considerable challenge worldwide, particularly during winter. Before the COVID-19 pandemic, serious infectious disease incidence had fallen with the success of vaccination programmes. However, amidst the ongoing global pandemic pressure on hospital EDs are stretched to their limit. This can strain health resources and budgets and can result in poor clinical outcomes. Increasing demand for EDs may be driven by rising morbidity in an ageing population, poor access to primary care and increase in patient expectations. In England, in 2017/2018, there were 23.8 million  emergency department attendances, an increase of 22% since 2008/2009; rises were higher in the under-5 (28%–30%), and one-third of all British children visit an  emergency department each year. Such increases pose immense challenges to the National Health Service (NHS) amidst significant cuts in funding, given that that nearly half of the health budget is spent on emergency and acute care.

We conducted an observational study using routine administrative data. Hospital Episode Statistics (HES) data covering all attendances at NHS hospitals in England for the period April 2014–March 2017 were used. We published our study in the Emergency Medicine Journal We found that one in 11 children (9.1%) who attended an  emergency department attended four times or more in a year. Infants, boys and children living in more deprived areas had greater likelihood of being a frequent attender. We concluded that infants and children living in deprived areas have greater likelihood of being frequent attenders. Interventions that support parents and contribute to reducing avoidable emergency department attendance, particularly among infants, are crucial to provide appropriate support to users of emergency departments.

DOI: http://dx.doi.org/10.1136/emermed-2019-209122