Dr Andy McKeown, Co-Course Director (Year5 MB BS Course Lead) and Dr Shivani Tanna (Year 3 GP Course Lead) have both received President’s Awards for Excellence in Teaching for 2017. These awards follow three similar awards received by our academic GPs in 2016 and showcase the fantastic teaching being delivered by the Department of Primary Care and Public Health.
On Thursday 21 September 2017, our Master of Public Health (MPH) students presented their research projects. This was the last assessment for the 2016-17 course. We had a wide-range of presentations on very topical issues in global health and health policy.
In a letter published in the British Medical Journal, I respond to comments from Dr David Shepherd and Dr Hendrik Beerstecher about an editorial I wrote on shortages of general practitioners in the NHS. Dr Shepherd argues that capitation-based funding for general practice can work if the total amount of funding was increase and better methods were used to allocate funds to general practices. Dr Beerstecher argues that there is a mismatch between the supply of general practitioners and demand for their services.
In my response, I state that that increasing the amount of funding for primary care would be a step forward. Moving from the current Carr-Hill formula for allocating budgets to general practices to a formula with more patient level clinical data would also be helpful. But case mix adjusted formulas such as the Johns Hopkins adjusted clinical groups (ACG) system have limitations—particularly when used for smaller populations such as those covered by the typical NHS general practice.
Furthermore, an entirely capitation based formula would not prevent the shift of unfunded work from specialist care to primary care, which is one of the major problems currently facing general practices and one that clinical commissioning groups in England seem unwilling or unable to tackle.
I agree with Dr Beerstecher about the mismatch between the supply of GPs in the NHS and demands for their services. I allude to this when I state that GP services might need to be scaled back to fit the public funding available. Demands on GPs could be reduced if practices had a more tightly defined contract with the NHS.
The current GP contract is vague and open ended, setting few limits on the quantity or range of services that GPs are expected to offer the NHS and their patients. Furthermore, government policy in recent years has been to encourage GPs to offer even more services and make themselves more available to patients—for example, by requiring GPs to open their practice for longer hours without a substantial increase in the GP workforce. These policies have led to higher demands on primary care.
GPs are also faced with patients expecting them to fill gaps in local health services. For example, patients with dental problems often present (inappropriately) to their GPs because of problems accessing dental services. These are all problems that need to be tackled by NHS commissioners.
Delayed diagnosis in primary care is a common, harmful and costly to patients and health systems. Its measurement and monitoring are underdeveloped and underutilised. A study from Imperial College London published in BMC Family Practice created and implemented a novel approach to identify problems leading to and solutions for delayed diagnosis in primary care. We developed a novel priority-setting method for patient safety problems and solutions called PRIORITIZE. We invited more than 500 NW London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to delayed diagnosis in primary care. 113 clinicians submitted their suggestions which were grouped into a composite list of 33 distinct problems and 27 solutions. A random group of 75 clinicians from the initial cohort scored these and an overall ranking was derived.
The top ranked problems were poor communication between secondary and primary care and the inverse care law, i.e. a mismatch between patients’ medical needs and healthcare supply. The highest ranked solutions included: a more rigorous system of communicating abnormal results of investigations to patients, direct hotlines to specialists for GPs to discuss patient problems and better training of primary care clinicians in relevant areas. A priority highlighted throughout the findings is a need to improve communication between clinicians as well as with patients. The highest ranked suggestions had the highest consensus between experts.
The novel method we have developed is highly feasible, informative and scalable, and merits wider exploration with a view of becoming part of a routine pro-active and preventative system for patient safety assessment. Clinicians proposed a range of concrete suggestions with an emphasis on improving communication among clinicians and with patients and better GP training. In their view, delayed diagnosis can often be prevented with interventions requiring relatively minor investment. Rankings of identified problems and solutions can serve as an aid to policy makers and commissioners of care in allocating healthcare resources.
Gatekeeping is the term used to describe the role of primary care physicians or general practitioners (GPs) in authorising access to specialist services and and diagnostic tests. Gatekeeping has important influences on service utilisation, health outcomes, healthcare costs, and patient satisfaction. In an article published in the British Medical Journal, we discuss the role of gatekeeping in modern health systems.
In the UK access to NHS and private specialists is generally possible only after a referral from a GP. Gatekeeping was developed as a response to a shortage of specialists and a desire to control healthcare spending and has been an accepted practice in the UK for many years. The NHS is under considerable pressure to use its resources efficiently, and GPs have helped the NHS to achieve this goal through managing a large proportion of NHS workload in primary care. However, GPs in the UK now find themselves under considerable workload pressures. In an 11-country survey of primary care physicians, it was GPs in the UK who had the shortest consultation lengths and were the most stressed. Could direct access to some NHS services help reduce GP workload and facilitate greater patient choice?
Internationally, there is a large variation in the role of primary care physicians in “gatekeeping”. In many countries, patients can access specialist services directly without a referral from a primary care physician (sometimes with a co-payment). Although it is often assumed that gatekeeping will help control healthcare costs, there is little association between the strength of gatekeeping in countries and the proportion of GDP spent on healthcare. Some countries with weak gatekeeping spend a relatively small proportion of GDP on healthcare (e.g. Singapore).
Within countries, there can also be differences in gatekeeping policies. In England, for example, there are large variations between clinical commissioning groups (CCGs) in policies for giving patients direct access to services. For example, some CCGs allow patients to have direct access to physiotherapy services.
In the article, we look at the pros and cons of gatekeeping, describe gatekeeping policies in various countries, and highlight the need for more evidence to devise policy. We conclude that gatekeeping policies should be revisited to accommodate the government’s aim to modernise the NHS in terms of giving patients more choice and facilitate more collaborative work between GPs and specialists. At the same time, any relaxation of gatekeeping should be carefully evaluated to ensure the clinical and non-clinical benefits outweigh the costs.
Former MPH student Vasundhra Khanna was selected to present her research at the World Innovation Summit for Health in Doha this November. Vasundhra told us about her research and her next steps.
“During my MPH at Imperial College in the 2014/15 academic year, I was inspired to pursue health promotion, primarily the nuances of formulating effective public health policy with greater relevance and utility in society. An opportunity to engage in such policy innovation was presented to me via the ‘Mini-Project’, coursework where students are asked to develop an innovative ‘health-intervention’ targeting real-world problems. The topic that caught my eye was inappropriate use of antibiotics and the serious consequences related to ‘antibiotic resistance’.
Antibiotic resistance in the developing world represents a major public health challenge. It is estimated that 10 in 10,000 people in Africa die as a result of antibiotic resistant bacteria, whereas, in Asia this is estimated to be 9 per 10,000 people. The incidence of resistance, however, seems to be worse in India, where up to 95% of adults carry bacteria resistant to β-lactam antibiotics. As a result, I decided to focus my intervention on India, the largest consumer of antibiotics globally. Antibiotic resistance in India emanates from patterns of inappropriate antibiotic prescription and consumption. Specifically, poorly managed health systems result in the unregulated over-the-counter sale of antibiotics and create a supportive environment for self-medication – the leading cause of improper antibiotic use throughout the country. This multifaceted nature of irrational antibiotic usage makes it difficult to develop a solution for regulating supplier and consumer attitudes.
Keeping that in mind, I chose to focus on affecting current consumer behaviours to curb inappropriate antibiotic consumption. Thus, my intervention concerns the development of home-based testing kits capable of distinguishing between bacterial and viral infections: Bac-Kits (Bacterial infection diagnosing-Kits). In this regard, I adopted a fully integrated Lab-on-a-disc ELISA system developed by Ulsan National Institute of Science and Technology (UNIST), Republic of Korea, and applied it to a novel signature of proteins, whose blood concentrations differ in response to bacterial and viral infections. The microbeads structure of the immunoassay on the discs allows the kits to have a competitive advantage over traditional ELISA by generating results using half the blood sample (150 μL) and within ~30 minutes. Each kit comes with pre-treated discs and a portable blood analyser with an easy interface – thereby, eliminating the need for technical skills and providing accurate diagnosis within the convenience of one’s home. This ensures scale-up to resource-constrained areas, where shortages of medical equipment and health workforce act as a barrier to healthcare. Although privately manufactured, cost-efficiency can be achieved through economiesof- scale.
Ultimately, by reducing inappropriate consumption of antibiotics in non-bacterial cases, Bac-Kits can contribute towards decreasing burden of resistance in the country. While the Mini-Project allowed me to develop the concept of this public health solution, the opportunity to make it a reality was presented to me by the World Innovation Summit for Health (WISH), where my idea was selected under the Young Innovator Programme 2016. WISH is a global healthcare community dedicated to identifying and disseminating the best evidence-based ideas and practices. At the summit in Doha in November, over 1,200 delegates are expected to attend, including national Ministers of Health, healthcare experts, industry leaders, investors and researchers. I aim to use this platform to establish my idea within the global public health community and gain guidance from industry experts and enthusiasts on making it a more robust intervention. Subsequently, I hope to collaborate with public health agencies in India to bring my innovation to life and contribute my share to curb the global disease burden.”
The NHS is currently aiming to develop a new capitation-based formula for funding general practices in England. My view is that a revised formula won’t address the fundamental problem with the current method of funding primary care: the disconnect between workload and funding. All the new formula will do – no matter how well-designed – is shuffle money between general practices. Some practices will gain substantial sums, some will lose substantial sums; but most practices will see no major changes in their funding.
Capitation-based formulas for general practices are therefore a 20th century solution that the government is trying to continue to use in the 21st century. We need to move away from a capitation-based funding model to one based on actual workload as well as on capitation. Under such a model, any work done by general practices – whether generated through government policy, patient demand or transfer of work from specialist settings into the community – would be paid for at its full cost. There would then be no need for any ‘funding formula’. The more work a practice did, the more it would get paid.
This is how primary care funded in many other developed countries and results in improved access to primary care services. Critics of workload-based funding for general practices might argue it would dramatically increase costs as well as being administratively complex to administer. However, the alternative is the continuation of current trends, with worsening access for patients to primary care services; and an exacerbation of GP recruitment and retention problems.
This blog was originally posed as a rapid response on the BMJ website.
MPH Course Director, Professor Azeem Majeed from the School of Public Health, was interviewed for the Faculty of Medicine Postgraduate Newsletter.
Q: Tell us a bit about yourself and what you do.
A: I am the Course Director of the Imperial College London Master of Public Health (MPH) programme. My other roles include being Professor of Primary Care and Head of the Department of Primary Care and Public Health at Imperial College London. I am also Associate Medical Director with the Imperial College Healthcare NHS Trust and an adviser to the World Health Organization (WHO) on primary care and public health. I remain active in clinical practice as a GP in the Clapham area of London.
Q: What were you doing before you joined Imperial?
A: I was formerly Professor of Primary Care & Public Health at University College London. I have also worked as a GP in the Clapham area of London since 1995.
Q: What (and who) inspired your research and teaching interests?
A: I undertook my GP training in the Pontypridd area of South Wales. I was struck by how many young patients I saw with problems such as heart disease and cancer. It was during this period I began to realise the importance of the wider non-medical determinants of health and the importance of topics such as health promotion, disease prevention and early diagnosis.
Q: What are the biggest challenges in your research field?
A: Health systems throughout the developed world are under increasing pressure to provide universal access to high quality services while at the same time trying to limit public spending on healthcare. This has led to an increased emphasis on ensuring that health services are of high quality, safe and cost effective; and that doctors and other health professionals base their clinical decisions on high quality evidence. There is also increased awareness of addressing risk factors for poor health such as smoking, unhealthy diets, physical inactivity and obesity.
Q: What do you enjoy doing in your free time?
A: I was formerly a qualified football referee but have had to give this up because of other commitments. In my spare time, I enjoy reading. I am also a member of the National Trust and enjoy visiting their parks and gardens.
Q: What advice would you give to new Masters students?
A: Attend your lectures, study hard, and practise academic writing. Read articles in relevant journals such as the BMJ and Lancet. Try to contribute to public and global health through membership of student societies and by writing for blogs.
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Dr Javier Salerno won a 2017 Lifetime Teaching Award from the School of Public Health for his contribution to teaching medical students from Imperial College London on primary care attachments. Dr Salerno accepted his award by sharing some reflections of what students have said to him over the years.
“I like this rotation as we do hands on medicine: it gives students the experience of seeing patients from very early days in their illness and the opportunity to see a lot of different patients.
I learned more medicine in this practice than in hospitals. I did not have a clue what I was going to do as a post graduate studies however after this rotation I am considering general practice very seriously. I will read my BMJ, NEJM, Lancet, JAMA on a weekly basis!
After diagnosing 3 melanomas on young people, they asked how did I find them if they had come for a flu like illness and chest infections. I asked them to remove their tops and melanomas were in rear dorsal areas and behind the arms. But why did you do that…..? Because of a 4 letter word which does not beginning with f (they did not have an idea of such word)…the word is CARE which they should also take as part of their education in medicine and humanity.
You are not just a GP, are you? (Stated several times by medical students) You are a reader of medicine aren’t you (most flattering compliment to me)?
Dr Salerno comments that “My aims for medical students: to make it very interesting, to share enthusiasm and humanity, care and compassion, friendship, up-to-date knowledge and above all fun! This is what they taught me in my medical school: San Fernando medicine faculty/San Marcos University, Lima, Peru.”
I was very honoured to have won the 2017 Lambeth CCG Award for Outstanding Contribution to Primary Care. Lambeth CCG noted that “Dr Majeed has made a huge contribution to primary care research and teaching, as well as providing high quality kind care to his patients in Clapham, where he has worked as a GP for over 20 years. Dr Majeed was also recognised recently in Pulse magazine as one of the 50 most influential GPs in the UK.”