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.

Why we need workload-based funding for general practices in England

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.

Faculty of Medicine Postgraduate Newsletter Features MPH Course Director, Professor Azeem Majeed

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.

The full newsletter can be viewed online

Dr Javier Salerno reflects on his experience of teaching medical students

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.”

Lambeth CCG 2017 Award for Outstanding Contribution to Primary Care

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.”

Imperial MPH Students win first prize in the “Vaccines Today Communication Challenge”

Two MPH students, Yewande Adeleke and Riham Arab, won the first prize in the “Vaccines Today” competition with their video promoting the MMR vaccine. We would like to congratulate them for their success. You can watch their video here.
This is the text accompanying the video: “Social media is a highly effective tool to use to improve awareness, encourage uptake and dispel myths associated with the MMR vaccine. So for the Vaccines Today Communication Challenge, we tried to display the content in an innovative, humorous and informative manner. The initial scene is to evoke a sense of duty and moral obligation amongst viewers. The target audience is both male and female adults. The transition from monochrome to coloured imaging is in parallel with the start of self-efficacious messaging and the MMR vaccination schedule is incorporated in the content. Finally, the video concludes with a herd of cows symbolising herd immunity and the #GetImmooonised slogan, can be used to encourage MMR vaccination on a variety of social media platforms”.

Imperial College GP Tutor Dr Christine Scott wins a 2017 Lifetime Teaching Award

Imperial College GP Tutor, Dr Christine Scott, won a 2017 Lifetime Teaching Award for her contribution to teaching medical students from Imperial College London. Here, she reflects on her experiences of teaching medical students.

Were you aware you were students’ inspiration and role model?
I think we often underestimate our impact on students. Now, as I read my feedback I recognise once again how extremely influential we are. What a great privilege, and what a great responsibility!

How long have you been teaching Imperial Medical Students for?
A lot of my embarrassment in receiving a lifetime teaching award is that I’ve only really been teaching at Imperial for about eight years. In a former era, I taught undergraduates from my alma mater, Newcastle University.

Why so long?
It hasn’t really been a very long time but I have been privileged to teach a number of different courses from first-year communication skills and First Clinical Attachment (FCA), doing some lecturing and teaching both in my practice and in the Department for Year 5 students on GP placement.

Why Imperial?
I really became involved in Imperial when I came along with a colleague to an introductory teaching session. It was a pragmatic decision, sessions were available and it’s my local medical school.

What kind of qualifications / CPD did you build up when teaching and how did this help you in this role?
Early on in my time teaching, I attended the Deanery Introduction to Teaching in Primary Care course (ITPCC). This really inspired me to be creative about the way I taught and gave me confidence to experiment, I really got a taste for it. Over the years, the annual GP teachers’ day and foundations of clinical practice (FoCP) conferences have been wonderful opportunities to learn. I always come not only with CPD credits but with my mind buzzing with new ideas of ways to teach and a whole new PDP for myself.

In what ways has teaching changed you and the way you practice medicine?
I think teaching has helped me to be more reflective and self-critical but also more confident. There is nothing like teaching something to ensure that you understand it well yourself and this is particularly true teaching within the clinical setting. My students have inspired me and challenged me to look at my practice through their young eyes. The skills of facilitation and feedback that I have learnt have had wider applicability working within the practice team. Lots of the teaching provided to us GP tutors at Imperial has also been extremely helpful. I look back gratefully on a number of memorable sessions, particularly those led by Giskin Day. Her teaching on medicine in the humanities has rekindled my love of reading and given me the courage to become creative!

Do you think hosting students has benefitted your GP practice, or the community you serve, in anyway?
The patients love talking to students and the perspective they bring, both on individual patients and on the service in general have been really useful. I think it also gives the whole practice a sense that they are contributing to the development of future doctors. In these days when we often feel tired and under pressure, it’s great to have the refreshing medical student perspective.

With the current NHS admin and recruitment pressures what would you be telling a family member if they were a GP and considering teaching?
Do it! The students you meet and the support and training you gain will be part of keeping you enthusiastic. When it works well, and it mostly does, the tutor-student partnership is formative for both parties, we change students but they change us. It is also clear from students that GPs are the people that really recognise them as individuals, adapt teaching to suit their learning needs and care about them – and that really counts. Finally, when I am old and unwell I want well taught and caring doctors to look after me!

Is there a memorable funny story from teaching you can imagine still recounting in the future?
I can’t really think of any funny stories, but certainly touching ones. The student who after his patient project was given a small silver teaspoon to remind him of parts of her story. My first year students performing a ballad to tell their patients story. Most recently two students explaining their patient’s illness using a wonderful model of a computer they had made as an allegory for his life.

We’ve heard about a beautiful house in France – tell us more about ‘life after being an Imperial teacher’
The beautiful house is on the edge of Paris and is part of my husband’s job. The main thing that will happen in my life after Imperial is being able to spend much more time in Paris with him making the most of all Paris offers. I’m also hoping to do some work developing appraisal with doctors working abroad and take some of my counselling skills to support our local church community. There will be plenty of time for coffee and museum visits and my Imperial friends will be warmly welcomed so keep in touch!

Can GPs issue private prescriptions to NHS patients?

The NHS prescription charge in England is currently £8.60 per item. At this level, many commonly prescribed drugs will cost less than the prescription charge and so some NHS patients may occasionally ask if they can have a private prescription rather than an NHS prescription.

In the past, some GPs have been advised that they could issue both an NHS FP10 and a private prescription, and let the patient decide which to use. But the British Medical Association’s General Practice Committee has obtained legal advice that said under the current primary care contract, GPs in England may not issue a private prescription alongside or as an alternative to an NHS FP10 prescription. In any consultation where a GP needs to issue an FP10, the concurrent issue of a private prescription would be a breach of NHS regulations.

The issuing of a private prescription in such circumstances could also be seen as an attempt to deprive the NHS of the funds it would receive from the prescription charge. Furthermore, for private prescriptions, the pharmacist is free to add a dispensing fee to the cost of the drug and so the patient might end up paying the same or even more than the NHS prescription charge for their private prescription. Finally, trying to explain NHS guidance on prescribing and its implications to the patient makes the issuing of a private prescription impractical in the time available.

Hence, I would advise GPs not to issue a private prescription to NHS patients in place of an NHS FP10 prescription in these circumstances. This advice should be communicated to the other prescribers in the practice so that they all follow the same policy.

Of course, the Department of Health could update its guidance and make it easier for NHS GPs in England to issue private prescriptions but there is no currently sign of this happening.

This article was originally published in the medical journal, Pulse.

Imperial College Master of Public Health (MPH) Programme

The Master of Public Health (MPH) programme at Imperial College London is a one-year course that provides a comprehensive introduction to public health for students intending to practise in public health or related fields. This video gives an overview of the course’s content and outlines the prospects for MPH graduates.

We aim to provide a comprehensive introduction to public health for students who intend to pursue careers in public health practice, management and/or research at local, national or international level. The course offers cutting-edge knowledge and skills base in the principles and methods of public health and a creative and supportive learning environment. The programme has special focus on the development of quantitative analytical skills for public health, epidemiology and health services research.

The economic burden of breast and cervical cancers in low and middle-income countries

Former Master of Public Health (MPH) student Natasha Kassami wrtes about her MPH research project.

“According to the World Health Organisation (WHO), Non-Communicable Diseases (NCDs) currently constitute the largest share of deaths worldwide (38 million deaths each year) with nearly three quarters of these deaths occurring in low- and middle-income countries (LMICs). Among these, cancers constitute the second largest proportion of NCD deaths and it has been suggested that a disproportionate amount of this burden falls on women in these regions who face the challenge of gender inequality in addition to the lack of access to cancer care, which results from their geographical predisposition.

It is fair to say that for a long time, I was relatively ignorant of the threat NCDs like cancer posed to low-resource populations. My attention was always drawn to infectious diseases like malaria, HIV/AIDS, TB, which have been the focus of public health campaigns in Uganda for many years. Needless to say I had suffered from Malaria countless times as a child in Uganda. My final year MPH dissertation came around the same time the threat of cancer became real to me. It was towards the end of the second semester of my Master’s program that I found out my hero, mentor and the head of my family, my father was being treated for colorectal cancer. His illness was an apt reminder of the significance of the research I was doing for my final year dissertation. That and the constant support and encouragement I received from my supervisors, Dr. Lesong Conteh (Senior Lecturer in Health Economics, Imperial College London) and Dr. Ophira Ginsburg (Medical Officer, World Health Organization, Geneva, Switzerland) and Dr. John Tayu (Assistant Professor, National University of Singapore), prompted me to work tirelessly on the summer project, which was a Systematic review on the ‘Economic Burden of breast and cervical cancers in LMICs’.

The review generated a landscape analysis, of sorts, for the current state of economic literature on the burden of these cancers in LMICs. We focused on these two cancers as they are the predominant causes of cancer morbidity and mortality in women around the world. Through our review, we identified several gaps in the research in low resource settings in comparison to High Income Countries (HICs). For example, while there is a growing evidence base on the cost effectiveness of specific interventions to address breast and cervical cancer in low-income countries (LICs), there is a paucity of studies evaluating the wider economic burden of breast cancer at both the household and the national level. Which suggests that the full economic cost of women’s cancer has not yet been realised. Furthermore, there is little research on the cost of advocacy, primary and secondary prevention of breast cancer in LMICs and the economic implications of a diagnosis in the younger, more productive years of a woman’s life are vast and rarely estimated in the literature.

Through the persistence of my amazing supervisors this study was able to have a greater impact than I could have ever achieved on my own, with its findings contributing to a paper on “The global burden of women’s cancers: a grand challenge in global health” which in turn was part of “The Lancet Series on ‘Health, Equity and Women’s Cancers’. The series, which was spearheaded by Dr. Ginsburg featured contributions of many formidable names in Cancer policy and research. Our paper in the series described the burden of breast and cervical cancer in relation to mortality, incidence survival and their implications on socioeconomically disadvantaged women (a subject Dr. Conteh and I contributed towards). I’m forever indebted to my supervisors for ensuring our work that summer was not shelved away and for pursuing it even after I graduated from the School of Public Health. We are currently working on publishing the original Systematic Review.”

Senator Bernie Sanders highlights a recent Imperial College paper on primary care

US Senator Bernie Sanders shared a recent paper from Imperial College London on his Facebook page. The paper highlighted the importance of expanding universal health coverage to reduce ‘avoidable’ deaths among Brazil’s black and mixed-race populations. The paper was published in the journal PLoS Medicine.

Dr Thomas Hone, Professor Christopher Millett, Professor Azeem Majeed from the Department of Primary Care and Public Health, and the School of Public Health, at Imperial College London and their colleagues from Fiocruz in Brazil analysed mortality data from 2000-2013 to determine the effect of Brazil’s Family Health Strategy (FHS) on avoidable deaths in black and mixed-race Brazilians compared to white Brazilians.

We found that rates of avoidable deaths were between 17% and 23% higher in black and mixed-race populations than in the white population during 2000-2013.