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.

How can medical students be encouraged to consider primary care as a career?

In a letter published in the British Journal of General Practice, medical students Fahmida Mannan and Zain Chaudhry from the Imperial College London School of Medicine discuss how the NHS and medical schools can encourage students to consider general practice as a career option. They suggest the focus in medical schools should shift towards improving the quality of general practice placements and promoting the integration of primary care and specialist teaching, rather than consuming more time in an already overstretched curricula.

They also consider that prestige has never been the main incentive for pursuing a specialty. Their own experience is that many medical students are attracted to a career in general practice because of other factors, such as a good work–life balance, continuity of care and career flexibility. With many GPs now concerned about their workload, this inevitably influences students and junior doctors in their career choices.

Another key factor is the funding that a specialty receives. In recent years, the proportion of the NHS budget spent on primary care has decreased, GPs’ workload has increased and the income of GPs has fallen. To recruit more GPs, medical schools should improve the quality of students’ experiences in their primary care placements. However by itself, this will not be sufficient to improve recruitment and the onus falls upon the NHS to once again make general practice a rewarding career for doctors.

We are now seeing some signs of this. For example, the NHS England Five Year Forward Strategy emphasises the importance of primary care to the NHS and proposes new employment models for general practitioners. This includes the formation of GP Federations in which general practitioners will come together to work in larger groups; and the possibility that hospitals could also employ GPs and offer primary care services.

Community Outreach in West London

Members of the School of Public Health held a very productive and informative meeting today with senior members of Imperial College including Sarah Waterbury, Vice President (Advancement); Maggie Dallman, Associate Provost (Academic Partnerships); Angela Bowen, Director of Development (Faculty of Medicine); and Tom Pearson, Head of Special Projects (Academic Partnerships).

The Department of Primary Care & Public Health in the School of Public Health works with local community stakeholders – such as voluntary groups, local authorities, and general practitioners – on a range of community-based outreach projects. These projects aim to improve the health and wellbeing of local residents; improve access to professional careers for children from deprived backgrounds; and give medical students experience of working with deprived and marginalised groups to develop skills in health coaching and behavioural change. This work is in addition to the very high-quality teaching and research programmes undertaken by the department.

Objectives for the future include developing a central coordinating function to bring this outreach work together; and integrate better with ongoing academic work in the Department of Primary Care and Public Health, the School of Public Health, the Faculty of Medicine, and Imperial College. We also need to expand the academic outputs from this work – such as conference presentations and journal articles – and give our students and clinical trainees greater opportunities to play a role in this work, thereby improving their skills and also the well-being of our local population.

 

Proportion of emergency admissions via A & E increasing while the proportion via GPs falling

In a paper published in the Journal of the Royal Society of Medicine, a team from Imperial College London examined time trends in emergency hospital admissions via accident and emergency departments in England. The proportion of emergency hospital admissions in which patients were admitted via an A and;E department increased markedly in England between 2001–2002 and 2010–2011.

There are several possible explanations for this trend. These include coding changes and the greater use of A and E departments to assess patients before they are admitted as emergencies. Changes in access to general practitioners – both during normal working hours and out of hours – may also have contributed to these changes.

The findings of the study in the JRSM are similar to those from studies in the United States. Future health policy should address gatekeeping in A  and E departments and the provision of urgent care in general practice  New models of care such as urgent care services that employ GPs in A and E departments as the gatekeepers to specialist urgent care may help in addressing this challenge but must be evaluated before they are scaled up.

The article was covered in Pulse and GP.

Electronic learning could enable millions more students to train as doctors and nurses worldwide

Electronic learning could enable millions more students to train as doctors and nurses worldwide, according to research carried out by the Department of Primary Care and Public Health at Imperial College London.

A review commissioned by the World Health Organization (WHO) and carried out by Imperial College London researchers concludes that eLearning is likely to be as effective as traditional methods for training health professionals.

eLearning, the use of electronic media and devices in education, is already used by some universities to support traditional campus-based teaching or enable distance learning. Wider use of eLearning might help to address the need to train more health workers across the globe. According to a recent WHO report, the world is short of 7.2 million healthcare professionals, and the figure is growing.

The Imperial team, led by Dr Josip Car, carried out a systematic review of the scientific literature to evaluate the effectiveness of eLearning for undergraduate health professional education. They conducted separate analyses looking at online learning, requiring an internet connection, and offline learning, delivered using CD-ROMs or USB sticks, for example.

The findings, drawn from a total of 108 studies, showed that students acquire knowledge and skills through online and offline eLearning as well as or better than they do through traditional teaching. The authors suggest that combining eLearning with traditional teaching might be more suitable for healthcare training than courses that rely fully on eLearning because of the need to acquire practical skills.

Dr Josip Car, from the Department of Primary Care and Public Health in the School of Public Health at Imperial College London said: “eLearning programmes could potentially help address the shortage of healthcare workers by enabling greater access to education, especially in the developing world the need for more health professionals is greatest.

“There are still barriers that need to be overcome, such as access to computers, internet connections, and learning resources, and this could be helped by facilitating investments in ICT. Universities should encourage the development of eLearning curricula and use online resources to reach out to students internationally.”

The full text of the review can be viewed online.

News items on the report were published in the Nursing Times and in the Examiner as well as by Reuters.

Giving patients online access to their electronic health records and linked online services

Online access to medical records by patients has the potential to promote patient-centred care and improve patient satisfaction.  Online services may also offer patients greater convenience although concerns remain about privacy and confidentiality. However, online access and services may also prove to be an additional burden for healthcare providers who are already under considerable workload pressures.

In a study published in the British Journal General Practice, I and colleagues form other UK universities assessed the impact of providing patients with access to their general practice electronic health records (EHR) and other EHR-linked online services on the provision, quality, and safety of health care. We carried out a systematic review that focused on all studies about online record access and transactional services in primary care.

We identified 176 studies, 17 of which were randomised controlled trials, cohort, or cluster studies. Patients reported improved satisfaction with online access and services compared with standard provision, improved self-care, and better communication and engagement with clinicians. Safety improvements were often patient-led; for example, through identifying medication errors and facilitating increased use of preventive services.

Provision of online record access and services resulted in a moderate increase of e-mail contact but no change on telephone contact. There were variable effects on face-to-face contact. However, other tasks were necessary to sustain these services, which impacted on clinician time. There were no reports of harm or breaches in privacy. In general online access to EHRs and online services was generally positive in its impact on areas such as patient satisfaction and patient safety.

The findings from this review are important for health systems and professionals. Although online access may be achievable, there remain challenges about clinicians’ adoption of systems because of workload and workflow concerns. The business model for primary care may also need to change to enable more effective utilisation of information technology in everyday practice.

Research using primary care databases in the United Kingdom

Data collected in electronic medical records for a patient in primary care 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 (UK) to facilitate the use of research data generated from consultations between primary care professionals and their patients.

In a study published in the Journal of Innovation in Health Informatics, we carried out a bibliometric review to analyse the research outputs and the longitudinal growth in the number of publications that harness the three main UK primary care databases: CPRD, QResearch and THIN.

These databases collectively produced 1,296 publications over a ten-year period, with CPRD producing 63.6% (n=825 papers), THIN 30.4% (n=394) and QResearch 5.9% (n=77). Pharmacoepidemiology and General Medicine were the most common specialities featured.

The growth in publications from these databases shows that they are making an important contribution to biomedical research in the UK. To continue to promote academic research using primary care databases, General Practitioners will need to continue to provide complete and accurate data; set standards will also need to be provided to General Practitioners to encourage enthusiasm and willingness to enter the required data;and public support encouraged for the continued use of
these databases for research that benefits the health of the population of the UK.

DOI: http://dx.doi.org/10.14236/jhi.v24i3.942

Setting more ambitious targets for general practices may not improve quality of care

Pay for performance programmes are being adopted in a growing number of countries as a quality improvement tool. In 2004, the United Kingdom introduced the Quality and Outcomes Framework (QOF) which primarily aimed to improve the management of common chronic conditions, such as diabetes and stroke, in primary care. The Department of Health in England is now considering allowing more flexibility in local pay for performance schemes, such as the introduction of higher payments for meeting tougher performance targets.

Research carried out at Imperial College London suggests that such local pay for performance schemes can improve target achievement by general practices but have no significant impact on the overall quality of clinical care. The study was funded by the NIHR and the NW London Collaboration for Leadership in Applied Health Research and Care (CLAHRC) and published in the journal PLoS One.

In the study, which was carried out by a team from the Department of Public Health and Primary Care at Imperial College London, the impact of a local pay for performance programme (QOF+), which rewarded financially more ambitious quality targets (‘stretch targets’) than those used nationally in the Quality and Outcomes Framework (QOF) was examined. The research team focused on targets for intermediate outcomes in patients with cardiovascular disease and diabetes. The team also analysed patient-level data on exception reporting. Exception reporting allows practitioners to exclude patients from target calculations if certain criteria are met, e.g. the patient has a terminal illness or gives informed dissent from treatment.

The team found that the local pay for performance program led to significantly higher target achievements for the management of hypertension, coronary heart disease, diabetes and stroke. However, the increase was driven by higher rates of exception reporting in patients. There were no statistically significant improvements in mean blood pressure, cholesterol or HbA1c levels. Thus, achievement of higher payment thresholds in the local pay for performance scheme was mainly due to increased exception reporting by practices. This may have been because the patients who were not exception-reported would not have benefited from more intensive treatment. There were no significant improvements in overall quality of clinical care once exception reporting was taken into account.

Hence, active monitoring of exception reporting should be considered when setting more ambitious quality targets for primary care teams. Some policy-makers and health service managers may consider giving practices less scope to exclude patients from pay from performance targets in an attempt to improve quality of care. Conversely, pay for performance programmes should not encourage over-treatment or inappropriate treatment; and exception reporting of suitable patients should always be allowed. Patients should also always be fully involved in decisions about their care and decide whether the incremental benefits of more intensive treatment will outweigh the potential problems (for example, from more intensive control of glucose in people with diabetes).

Why pledges from politicians on NHS primary care need careful examination

The likely effects of the Conservatives’ and Labour’s pledges to improve access to primary care are unclear. Both main parties have promised large increases in the number of GPs and significant improvements in access to appointments. In an article published in the the British Medical Journal, Thomas Cowling and Matthew Harris and myself – from the Department of Primary Care and Public Health at Imperial College London – say the pledges are unlikely to be achieved within a single parliamentary term.

The Labour Party have pledged to recruit 8,000 new GPs and plan to reintroduce their guarantee of an appointment within 48 hours. This target was far from being achieved under the last Labour government, with only 81 per cent of patients able to see a GP within two weekdays in 2009-10. As well as recruiting 5,000 extra GPs, the Conservatives have promised that if they are re-elected, patients in England will be able to see a GP between 8am and 8pm, seven days a week. This policy has been piloted in 14 per cent of GP practices, but results of an independent evaluation are yet to be published.

Thomas Cowling, NIHR Doctoral Research Fellow in the School of Public Health at Imperial College London, said: “Both parties have made bold promises about access to GP services, but the evidence behind their pledges is lacking. It’s important that policies like extended access are independently evaluated before being implemented more widely.”

“The pledges on increases to the GP workforce are very ambitious and unlikely to be met within a parliamentary term. The NHS should follow research evaluating new types of appointment that have been proposed to increase GP capacity, such as consultations and triage by phone or online. It should also consider other types of staff who could take on some of the work of GPs.”

“I also suggest looking at ways to reduce demand for GP services, like providing pharmacist-led minor illness services, and investing in public health programmes that could reduce primary care demand in the long run through improving the population’s health, which is the most important thing.”

The BMJ article discusses the aims of the parties’ pledges and looks at the evidence for how effective they would be. The largest increase in the GP workforce over any previous five-year period was 5,414, from 2004 to 2009. Last year, a GP Taskforce report identified major recruitment and retention problems that need to be tackled to increase GP numbers, including a shortage of GP training posts.

Both Labour and the Conservatives claim that their policies will reduce attendance at A&E departments. Although some studies have found an association between GP access and lower rates of A&E visits and emergency admissions, there is a lack of evidence that improving access over time reduces the demand for other services.

Although both parties appear to see access to primary care as a serious problem, we point out that international comparisons typically rate the UK highly, such as a recent assessment of 11 high-income countries that ranked the UK top for access to healthcare. Approximately 90% of patients in England were able to get a general practice appointment on their last attempt to do so, according to national patient survey data.

We conclude the article with five points of action for policy and research:

  • Evaluate the existing pilot scheme of extended general practice opening hours
  • Make more data on the work done in primary care routinely available
  • Discuss the mix of staff in general practice
  • Evaluate new types of appointment (e.g. phone and online)
  • Give due consideration to increases in demand for general practice when designing policies

The article received widespread coverage in media outlets such as the Independent, Sky News, Yahoo, Daily Mail and Newsweek.

Alternative providers of GP services perform worse than traditional practices

A study from Imperial College London reports that alternative providers of primary care in the NHS, including private sector companies, do not perform as well as traditional GP practices when their performance is assessed using a range of measures of quality of care.

Alternative providers have been contracted to offer primary care in the NHS since 2004 under reforms designed to increase competition. These providers performed worse than traditional GP practices on 15 out of 17 indicators after adjusting for the characteristics of the practices and the populations they serve.The study was published in the Journal of the Royal Society of Medicine.

“This study provides data to inform the debate about the growing role of the private sector in the NHS,” said Dr Christopher Millett, lead author of the study, from the School of Public Health at Imperial. “New providers were allowed into the primary care market to stimulate competition, but our findings suggest that their introduction has not led to improvements in quality and may have resulted in worse care.

“The lesson is that increasing diversity does not necessarily lead to better quality. Regulators should ensure that new providers of NHS services are performing to adequate standards and at least as well as traditional providers.”

Three hundred and forty-seven general practices – 4.1 per cent of practices in England – are run by alternative providers, including private companies and voluntary organisations. These practices tend to be smaller, and serve younger, more diverse and more deprived populations than traditional providers.

The study looked at a range of performance indicators from the Health and Social Care Information Centre and the national GP Patient Survey. These included access measures such as how easily patients can get appointments, clinical measures such as how well they manage patients’ blood pressure, and efficiency measures.

Among the differences between types of practices, alternative providers had worse results for patients’ diabetes control, higher hospital admission rates for chronic conditions, and lower overall patient satisfaction.

“So far, alternative providers have not been widely contracted to delivery primary care services,” said Dr Millett. “However, private sector providers have secured a third of contracts to deliver NHS clinical services since the Health and Social Care Act was enacted in 2013. Our findings highlight the need for careful and independent evaluation of how this legislation has impacted quality of care.”

The article was covered by a number of media outlets including the Independent, Pulse, Daily Mail, BMJ, GP Online, BT.Com and OnMedica.

Coverage of the NHS Health Check programme in England: national evaluation

An article from my research group examined coverage of the NHS Health Check programme in England. The article was published in the journal Preventive Medicine. We found that coverage of the programme was low in the first four years and there was a wide variation in coverage between general practice.

There was an increase in statin prescribing but only about one in three people who attended for a Health Check and who were found to have a cardiovascular risk score (20% or more 10-year risk of cardiovascular disease) were prescribed a statin.

We concluded that unless coverage of the NHS Health Check programme improved and uptake of statins in high-risk groups increased, the programme would not deliver its predicted benefits in reducing morbidity and mortality from cardiovascular disease.

The article was covered by a number of media outlets including the Daily Mail and Pulse.