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.

Seven-day access to NHS primary care: how does England compare with other European countries?

It is often assumed that providing easier access to community-based general practice during evenings and weekends can reduce demand for emergency and other unscheduled care services, promoting more appropriate care and reducing the costs associated with expensive hospital-based treatment. For example, in England’s NHS there is political pressure to expand general practice surgeries’ opening hours to progress towards a ‘seven-day NHS’.

When considering extension of primary care opening hours in England, it is useful to compare primary care access across other countries in the European Union. Despite differences in healthcare commissioning and funding, European countries face comparable challenges such as ageing populations and increases in chronic conditions and mental health problems, all of particular relevance to primary care.  In a paper published in the Journal of the Royal Society of Medicine, we examined England’s current in-hours general practice services relative to those of European countries in order to better contextualise the debate on extending general practice opening hours.

We found that standard opening hours in England already exceed those of most other European countries, and patients in the UK are more satisfied with out-of-hours access to general practice than patients in many other European countries. Achieving easier access to primary care services seven days per week would require significant investment, and must compete with other NHS priorities; politically attractive priorities should not to have an undue influence in shaping resource allocation.

The existence of true patient demand for extension of general practice opening hours in England is not yet fully established and evidence for a correlation between increasing in-hours provision and decreased emergency department use is inconclusive. Furthermore, the demand for services likely varies based on local demographics and disease burden; if general practice opening hours were to be extended, those regions with the highest demand for care should be prioritised.

Hence, we suggest that policy-makers in England should focus on improving access to GP appointments during normal opening hours, instead of spending scarce NHS resources on very poor value for money extended opening hours schemes.

https://doi.org/10.1177/0141076818755557

Extending GP opening hours will not ease the rising burden on A&E departments

A study published in the journal BMJ Quality and Safety concluded that extending GP opening hours will not ease the rising burden on Accident and Emergency departments. The observational study was led by Imperial College London. Lead author Dr Thomas Cowling from Imperial College’s Department of Primary Care and Public Health and colleagues compared patients’ experiences of GP surgeries with the number of Accident and Emergency visits in their areas in England from 2011-2012 to 2013-2014. They examined reports from NHS England’s annual GP Patient Survey, and included patients registered to 8,124 GP surgeries.

We measured levels of patient satisfaction using three factors: the ease of making an appointment, opening hours, and overall experience. They then matched these responses with A&E departments in their area to observe any correlation with the number of visits to A&E. Overall, areas where patients were happier with the ease of making appointments, which could be for example by using online booking systems, saw slightly fewer visits to Accident and Emergency departments. However, satisfaction with surgery opening hours and overall patient experience seemed to have no impact on Accident and Emergency visit rates.

The study suggests that better satisfaction with GP hours, for example because of extended opening hours, does not affect the number of visits made to A&E in their geographical area. However, making the appointment booking process easier for patients was associated with slightly fewer Accident and Emergency visits in that area. Our research supports finding alternative options for easing the burden on Accident and Emergency departments, and casts doubt on the Government’s proposals to extend GP surgery hours to ease the burden on Accident and Emergency departments.

We measured satisfaction with hours without linking explicitly them to daytime weekday or evening and weekend appointment availability. We hypothesised that although weekend and evening appointments are convenient for healthy, working aged adults, those who are likely to need medical attention more urgently are older people or those who are chronically ill and not currently working full time.

Senior author Professor Azeem Majeed from Imperial’s School of Public health, who is a practising GP, said: “The government must find alternative ways to handle current pressures on Accident and Emergency departments. This could include for example improving access to GP appointments during normal opening hours rather than spending scarce NHS resources on extended opening schemes.”

Dr Cowling, also from Imperial’s School of Public Health, said: “It makes sense to think that extending GP hours will ease the burden on other NHS services, but our study suggests this might not be the case with Accident and Emergency.”

The study was reported in a number of media outlets including the Times, Belfast Telegraph, OnMedica, Pulse and Eureka Alert.

Interested in our Integrated Clinical Apprenticeship? Read our FAQs

WHAT ARE MY MORNING COMMITMENTS?

Your Thursday morning and afternoon throughout your year 5 will be dedicated to the Integrated Clinical Apprenticeship. This has been negotiated with the Year 5 course leads and your Specialty supervisors for each firm. Attendance is mandatory for both morning and afternoon sessions. You will attend your allocated GP surgery on a time negotiated with your GP mentor. In the morning, you will see patients from your caseload, assessing their clinical needs and bringing yourself up to date with their secondary care contacts. You can then plan with your patient to attend any secondary care appointments in the coming weeks with your patients.  You may also see “ad hoc” patients from the surgery and, if relevant, add them to your caseload. There will be an opportunity to see other health professionals in the primary care team and assist in their daily activities.

WHAT IS MY PATIENT “CASELOAD”?

This is a group of about 12 patients (shared with your pair), recruited by your GP and you, who you will follow through the year, both in primary and secondary care. Depending on their clinical condition, you may not be required to follow them through the entire year, but other patients can be “picked up” through the year on an ad-hoc basis.

WHAT WILL I BE EXPECTED TO DO WITH MY PATIENTS?

You will be expected to see patients, assess them clinically, perform reviews (eg mental health and ante-natal reviews), manage your own appointments and home visits and perform investigations on your patients as required.

WHAT IF I FEEL I AM MISSING OUT ON FIRM OBLIGATIONS?

It will be up to you to decide whether some of the secondary care appointments will take precedence over commitments elsewhere in your firm. This will require discussion with your site leads as these arise. These negotiations are an important part of becoming a flexible clinician, requiring prioritisation and organisational skills.

WHAT ABOUT THE AFTERNOON?

Tutorials based in Imperial Campuses will start at 2pm and run until 5pm every Thursday. These will give you an opportunity to debrief with peers and course leads, present interesting cases (both from Integrated Clinical Apprenticeship and your firms) and receive tutorials based around course themes, relevant to the Year 5 core specialties.

ARE THERE ANY ASSESSMENTS OR WRITE UPs?

There are no formal assessments in the Integrated Clinical Apprenticeship. However, there are some exercises during the year that are designed to help you reflect on your Year 5 learning with regard to your Integrated Clinical Apprenticeship work.

WHAT IF I CAN’T ATTEND A SESSION?

You first priority in this instance is to your patients and your surgery. Please let them know as soon as possible that you cannot attend so that they can inform your booked patients. Please also email the course administrator Noosheen Bashir (n.bashir@imperial.ac.uk). You should always notify us prior to being absent from a session so that our records are accurate.

Research Outputs of England’s Hospital Episode Statistics Database

Hospital administrative data, such as those provided by the Hospital Episode Statistics (HES) database in England, are increasingly being used for research and quality improvement. To date, no study has tried to quantify and examine trends in the use of HES for research purposes. We therefore examined trends in the use of HES data for research. Our study was published in the Journal of Innovation in Health Informatics.

Publications generated from the use of HES data were extracted from PubMed and analysed. Publications from 1996 to 2014 were then examined further in the Science Citation Index (SCI) of the Thompson Scientific Institute for Science Information (Web of Science) for details of research specialty area. 520 studies, categorised into 44 specialty areas, were extracted from PubMed. The review showed an increase in publications over the 18-year period with an average of 27 publications per year, however with the majority of outputs observed in the latter part of the study period. The highest number of publications was in the Health Statistics specialty area.

We concluded that the use of HES data for research is becoming more common. Increase in publications over time shows that researchers are beginning to take advantage of the potential of HES data. Although HES is a valuable database, concerns exist over the accuracy and completeness of the data entered.

DOI: http://dx.doi.org/10.14236/jhi.v24i4.949

Research outputs of primary care databases in the United Kingdom: bibliometric analysis

Data collected in electronic medical records for a patient in primary care in the United Kingdom can span from birth to death and can have enormous benefits in improving health care and public health, and for research. Several systems exist in the United Kingdom to facilitate the use of research data generated from consultations between primary care professionals and their patients. General Practitioners play a gatekeeper role in the UK’s National Health Service (NHS) because they are responsible for providing primary care services and for referring patients to see specialists.

In more recent years, these databases have been supplemented (through data linkage) with additional data from areas such as laboratory investigations, hospital admissions and mortality statistics. Data collected in primary care research databases are now increasingly used for research in many areas, and for providing information on patterns of disease. These databases have clinical and prescription data and can provide information to support pharmacovigilance, including information on demographics, medical symptoms, therapy (medicines, vaccines, devices) and treatment outcomes.

We examined the number of research outputs from three primary care database, CPRD, THIN and QResearch, assessing growth and publication outputs over a 10-year period (2004-2013) in a study published in the Journal of Innovation in Health Informatics. The databases collectively produced 1,296 publications over a ten-year period, with CPRD representing 63.6% (n = 825 papers), THIN 30.4% (n = 394) and QResearch 5.9% (n = 77). Pharmacoepidemiology and General Medicine were the most common specialties featured.

Career opportunities for GPs in North and West London

On Wednesday 22 November 2017, I spoke at an event organised by the North and West London Faculty of the Royal College of General Practitioners. The event was aimed at ‘First Five’ general practitioners. I spoke on the topic of opportunities in research. The event was chaired by Dr Camille Gajria and Dr Nilesh Bharakhada. Other speakers at the conference included Dr Ian Goodman, Chair of Hillingdon CCG, who spoke on the topic of emerging opportunities for GPs through new models of care; Dr Sohail Hussain who spoke on media opportunities; Dr Krishan Aggarwal who spoke on finance; Dr Shivani Tanna who spoke on teaching opportunities; Dr Sonia Tsukagoshi who spoke on international opportunities; and Dr Nilesh Bharakhada who spoke on the Care Information Exchange and opportunities in technology for GPs. The event was a good opportunity for First Five GPs to learn about career opportunities in London and also update themselves on areas such as personal finance and key developments in the NHS in London, such as new care models.

Tobacco control efforts in the Gulf Cooperation Council countries

A paper published in the Eastern Mediterranean Health Journal  reviews the current state of tobacco use, governance and national commitment for control, and current intervention frameworks in place to reduce the use of tobacco among the populations of the Gulf Cooperation Council (GCC) member states and Yemen. It further reviews structured policy-oriented interventions (in line with the MPOWER package of 6 evidence-based tobacco control measures) that represent government actions to strengthen, implement and manage tobacco control programmes and to address the growing epidemic of tobacco use.

The findings of the review show that tobacco control in the GCC countries has witnessed real progress over the past decades. These are still early days but they indicate steps in the right direction. Future investment in implementation and enforcement of the Framework Convention on Tobacco Control, production of robust tobacco control legislation and the establishment of universally available tobacco cessation services are essential to sustain and strengthen tobacco control in the GCC region.

Why do patients attend general practitioner-led urgent care centres with minor illnesses?

The demand for urgent care is increasing, and the pressure on emergency departments is of significant concern. General practitioner (GP)-led urgent care centres are a new model of care developed to divert patients to more appropriate primary care environments. In a study published in the Emergency Medicine Journal, I along with colleagues from Imperial College London explored why patients with minor illnesses choose to attend an urban urgent care centre.

We used a self-completed questionnaire among patients aged 18 years or over (N=649) who were triaged with a ‘minor illness’ on arrival at an urgent care centre co-located with an emergency department in London. The median age of participants was 29 years. 58% (649/1112) of patients attending the centre with minor illness during the study period took part. 72% of participants were registered with a GP; more women (59%) attended than men; and the majority of participants rated themselves as healthy (81%). Access to care (58%) was a key reason for using the service as was expectation of receiving prescription medication (69%). GP dissatisfaction influenced 10% of participants in their decision to attend. 68% did not contact their GP in the previous 24 hours before attending.

We concluded that the GP-led urgent care centre was attracting healthy young adults, who were mostly registered with a GP and used services because of convenience and ease of access rather than satisfaction levels with their GP. An expansion of primary care capacity for patients with acute minor illnesses could reduce the number of patient who see their own practice rather than attend an urgent care centre.

Patients are more satisfied with general practices managed by GP partners than those managed by companies.

General practices in England are independent businesses that are contracted to provide primary care for specified populations. Most are owned by general practitioners, but many types of organisation are now eligible to deliver these services. In a study published in the Journal of the Royal Society of Medicine, we examined the association between patient experience and the contract type of general practices in England, distinguishing limited companies from other practices.

We analysed data from the English General Practice Patient Survey 2013–2014 (July to September 2013 and January to March 2014). Patients were eligible for inclusion in the survey if they had a valid National Health Service number, had been registered with a general practice for six months or more, and were aged 18 years or over. All general practices in England with eligible patients were included in the survey (n = 8017).

Patients registered to general practices owned by limited companies reported worse experiences of their care than patients registered to other practices on average. This applied to practices recorded as limited companies in routine contract data and to practices owned by large organisations. The sizes of the differences in experience varied from moderate to large across four outcome measures and were largest for the frequency of consulting a preferred doctor. Limited company ownership of general practices is uncommon in England. Patient experience was not consistently associated with the contract type for practices not recorded as limited companies. Across all contract and ownership types, patients generally reported positive experiences of their general practices.

Although our results suggest that limited companies provide worse patient experiences on average, some practices owned by these companies provide a good experience; others provide the opposite. It is the responsibility of commissioners, regulators, clinicians and owners to guarantee that individual practices meet expected standards while ensuring that care quality is not systematically associated with the ownership. Commissioners also need to ensure that contracts offer good value for money, more so at a time when the National Health Service is under severe financial pressure.

Reorganisation of stroke care and impact on mortality in patients admitted during weekends

In a study published in BMJ Safety and Quality, we evaluated mortality differences between weekend and weekday emergency stroke admissions in England over time. We aimed to determine whether a reconfiguration of stroke services in Greater London was associated with a change in this mortality difference.

We extracted patient-level data from national routinely collected administrative data (Hospital Episode Statistics or HES) from 1 January 2008 to 31 December 2014. Records include information of all admissions to English National Health Service (NHS) hospital trusts. Each patient record contains information on demographics (such as sex, age and ethnicity), the episode of care (such as trust name, date of admission) and diagnosis.

Our study covers a 30-month period before (January 2008 to June 2010) the reorganisation of stroke service in Greater London, and a 54-month period afterwards (July 2010 to December 2014). All admissions during the same period in the rest of England were used as controls.

Across England, the higher 7-day and 30-day in-hospital mortality risk associated with patients with stroke admitted during weekends compared with weekdays declined during the study period, to the extent that it was no longer statistically significant in the most recent year (2014). In Greater London, an adjusted 28% (RR=1.28, 95% CI 1.09 to 1.47) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 9% higher risk (RR=1.09, 95% CI 0.91 to 1.32) in 2014. For the rest of England, a 15% (RR=1.15, 95% CI 1.09 to 1.22) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 3% higher risk (RR=1.03, 95% CI 0.97 to 1.10) in 2014. During the same period, in Greater London an adjusted 12% (RR=1.12, 95% CI 1.00 to 1.26) weekend/weekday 30-day mortality ratio in 2008 slightly increased to 14% (RR=1.14, 95% CI 1.00 to 1.30); however, it was not significant.

While other research has suggested that centralisation of stroke care in London is associated with better outcomes generally, we in addition observe a gradual reduction in the weekend effect for emergency stroke admissions across England between 2008 and 2014. Although we cannot rule out an effect from centralisation, we found no statistical association with the reorganisation of services in London. This is unlikely to be due to changes in casemix or coding, and is consistent with a more general pattern of service improvement across the country with increased specialisation, as well as improved 24/7 delivery of care. While we have not specifically looked at staffing levels, it has not escaped our notice that our observed reductions in the ‘weekend effect’ occurred before any contractual changes for medical staffing in the UK.