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.

Exploring the Impact of Diagnostic Timeframes on Multimorbidity Prevalence in England

Our study in published in BMJ Medicine in February 2024 examined the effect of defining timeframes for long-term conditions on the prevalence of multimorbidity in England, and on the role played by sociodemographic factors. Using primary care electronic health records from the Clinical Practice Research Datalink Aurum, the study included over 9.7 million adults registered in England as of 1 January 2020, focusing on 212 long-term conditions.

Key Findings

Varying Prevalence Rates: The prevalence of multimorbidity, defined as the coexistence of two or more long-term conditions, varied widely based on the timeframe used for definition. It ranged from 41% with stricter criteria (requiring three codes within any 12-month period) to a 74% when a single diagnostic code was deemed sufficient. Using conditions marked as active problems resulted in the lowest prevalence rate at 35%.

Sociodemographic Influences: The study revealed that younger individuals, certain minority ethnic groups, and those living in areas of lower socioeconomic deprivation were more likely to be reclassified as not multimorbid under timeframes that required more than one diagnostic code. This suggests that these groups are disproportionately affected by the criteria used to define long-term conditions.

Implications for Healthcare Policy and Research: The substantial variation in multimorbidity prevalence underscores the challenges in directly comparing estimates of multimorbidity between studies. It highlights the need for clear rationales behind the choice of timeframe and suggests a potential bias introduced by definitions requiring multiple codes. We recommended that researchers provide their reasoning for the timeframe choice and consider sensitivity analyses to explore the impact on different patient groups.

Addressing Multimorbidity in Healthcare

The findings emphasize the complexity of measuring multimorbidity and the influence of methodological decisions on prevalence estimates. This has important implications for healthcare policy, practice, and research; stressing the importance of adopting a nuanced approach to understanding and addressing the needs of people with multiple health conditions. It calls for a balance between the granularity of condition definitions and the practicality of healthcare delivery, ensuring that healthcare systems can adequately respond to the nuanced needs of its diverse patient population.

Conclusions

The study serves as a critical reminder of the dynamic nature of health conditions and the need for healthcare systems to adapt their approaches to effectively manage multimorbidity. It opens avenues for further research into optimising care for individuals with multiple long-term conditions, ultimately aiming to enhance clinical outcomes, patient experience quality of life, and healthcare efficiency.

Tackling Sickness Absence in the NHS: The Importance of Staff Well-being on Healthcare Delivery

The National Health Service (NHS) in England requires the ability to maintain adequate staffing levels across all professional groups. A crucial aspect of this challenge is managing sickness absence rates among NHS staff, which not only impacts patient care and operational costs but also plays a pivotal role in workforce retention and overall healthcare efficacy. Our recent paper in the Journal of the Royal Society of Medicine discusses this important challenge for the NHS.

Recent data published by NHS Digital indicates a worrying trend: sickness absence rates have been on a steady rise across all NHS staff groups since 2009, with a notable surge during the COVID-19 pandemic. This trend has resulted in absence rates remaining elevated above pre-pandemic levels, signaling a potential crisis in staffing and healthcare delivery.

The Dynamics of Sickness Absence Rates

Before the pandemic, monthly sickness absence rates typically varied between 4% and 5%, with expected seasonal variations. However, the pandemic era saw these rates spike to around 6%, and even after the lifting of most COVID-19 restrictions, they have hovered between 5% and 6%. In comparison, the general UK workforce has exhibited more stable sickness absence rates, with NHS employees displaying approximately double the absence rates of their counterparts in other sectors. This disparity underscores the unique pressures faced by NHS staff, including high-stress environments and demanding physical work conditions.

Mental Health at the Forefront

A significant finding from the NHS England data is the high prevalence of mental ill health, particularly anxiety and depression, as a leading cause of sickness absence among NHS staff. This contrasts with the broader employment landscape, where other illnesses predominate. The data suggests that NHS staff are substantially more likely to take leave for mental health reasons, a situation likely exacerbated by the demanding conditions of NHS work environments.

Variations and Implications for Policy

Sickness absence rates vary across different professional groups within the NHS, with doctors generally showing lower rates than other groups such as nursing, ambulance, and allied health professionals. This variance highlights the need for a nuanced approach to addressing sickness absence, considering factors such as role flexibility, work conditions, and the potential for presenteeism.

Addressing these issues requires more than reactive measures; it demands a proactive strategy that includes improving access to occupational health services, mental health resources, and implementing systemic changes to address the root causes of high sickness absence rates. The NHS workforce plan looks to the national Growing Occupational Health and Wellbeing Strategy for solutions, but there is a clear need for more comprehensive, data-driven approaches that tackle the underlying factors contributing to workforce strain.

Conclusions

Ultimately, understanding and mitigating the reasons behind elevated sickness absence rates – particularly those related to mental health and varying across professional groups – will be crucial for closing the gap between the NHS and the broader UK workforce. This effort will not only enhance workforce well-being but also ensure the sustainability of high-quality healthcare delivery within the NHS.

How can we make a success of Pharmacy First?

Pharmacies in England to begin treating patients for seven common conditions. How can we work successfully across the health and care system to make a success of Pharmacy First?

1. The Pharmacy First scheme aims to provide convenient access to healthcare through community pharmacies. Patients with minor ailments or common conditions can seek advice and treatment directly from their local pharmacy instead of visiting a general practice, urgent care centre or emergency department. The conditions covered by the scheme may vary depending on local funding arrangements and participation of pharmacies.

2, A potential problem with Pharmacy First is pharmacists misdiagnosing a patient’s condition. It may also lead to delays in patients seeing doctors when medical assessment is needed. To mitigate these risks, appropriate safeguards and referral pathways should be established, ensuring timely medical assessment when necessary. The scheme will also increase the workload of pharmacies, thereby reducing the time available for other areas of work.

3. To ensure the successful implementation of Pharmacy First, it is essential to develop strong partnerships between key partners in the scheme such as pharmacies, general practices, and integrated care boards. Good communication to share information, updates about the scheme and best practice among all organisations involved is also needed; as is ensuring clear roles and responsibilities for all partners in the scheme.

4. The use of guidelines and protocols that outline the specific tasks, workflows, and processes involved in the scheme will ensure that all partners are aware of their responsibilities. This will keep partners well-informed about their responsibilities and help maintain consistent standards. Comprehensive training and educational resources for community pharmacists and other pharmacy staff are also needed, including continuous professional development and regular audits of clinical practice.

5. The NHS needs to integrate IT systems between pharmacies and general practices to facilitate efficient and accurate transfer of patient information, and to ensure good continuity of care. Additionally, the use of digital technologies and telehealth solutions should be explored to enhance follow-up and patient monitoring when required.

5. As Pharmacy First is relatively new, robust performance monitoring and evaluation are needed to assess its costs, clinical effectiveness, effects on other parts of the NHS and impact on patient satisfaction. This requires the development of key performance indicators to measure the scheme’s outcomes in these areas, enabling evidence-based decision-making and continuous quality improvement.

6. Improving public awareness and engagement is crucial. Implementing media campaigns to inform the public about the scheme’s availability and benefits will help drive its adoption. Furthermore, proactive engagement with patients, community groups, and other stakeholders, particularly those from underserved groups, will ensure inclusivity and provide valuable feedback for ongoing improvement of the scheme.

References

1. Clinical pharmacists in primary care: a safe solution to the workforce crisis? https://journals.sagepub.com/doi/full/10.1177/0141076818756618

2. Impact of integrating pharmacists into primary care teams on health systems indicators: a systematic review. https://bjgp.org/content/69/687/e665.full

Strategies to Address Drug Shortages in the UK’s NHS

In recent years, the UK has repeatedly suffered from shortages of many key drugs. As well as creating extra work for doctors and pharmacists, these shortages are also very stressful for patients. The government has recently published details of how it might address this issue. We need effective implementation of these plans as well. In particular, we need a combination of a strong UK manufacturing base to produce the drugs the NHS needs along with secure contracts with overseas suppliers.

Developing a robust domestic manufacturing base for pharmaceuticals offer several benefits. It reduces reliance on international supply chains, which can be vulnerable to global events, trade disputes, and logistical challenges. UK manufacturing can also facilitate quicker responses to the UK’s health needs and stimulate economic growth and job creation within the UK. However, building such infrastructure requires substantial investment, time, and expertise.

While bolstering domestic production, it is also essential to maintain strong relationships with overseas drug suppliers. Diversifying the source of pharmaceuticals mitigates the risk of shortages due to domestic production issues. Secure, long-term contracts with foreign suppliers can help ensure a steady supply of essential drugs, but these agreements must be carefully managed to ensure they are resilient to global market and political fluctuations.

Relying on the “free market” and a laissez-faire attitude won’t be nearly enough to tackle the problem. Drug manufacturing and supply problems a major global health concern. The UK government should actively engage in international dialogues and collaborations to address wider challenges that impact drug availability.

Improving measles (MMR) vaccine uptake in primary care

The UKHSA has warned that the UK is seeing a surge in measles cases; putting at risk the health of children and others who are unvaccinated. What can primary care teams do to boost measles vaccine uptake in their patients and help bring the number of measles cases down?

In this post, I list some of the key steps in implementing measles (MMR) vaccination in your practice and raising vaccine uptake. This guidance can also be used by primary care providers in other countries.

1. Give one member of the practice team responsibility for leading the vaccination programme, supported by the wider practice team.

2. Ensure that all staff are informed about the programme; including who is eligible; and the benefits of vaccination for the individual patient, their family, the NHS and society. There are many free online programmes on vaccination and addressing vaccine hesitancy for health professionals. Ensure that vaccination is discussed regularly at team meetings to review progress and address challenges.

3. Prepare FAQs to common questions from patients. These are usually available on government websites such as those published by NHS England and the UKHSA. Ensure staff know where to look for these FAQs, which are essential in countering misinformation about MMR vaccination. Specific training is available in effective communication strategies to address vaccine hesitancy and misinformation during patient interactions.

4. Ensure medical records are as accurate as possible so that patients are not called for vaccination inappropriately. This is particularly important in large urban areas where population mobility is high and vaccine records may not always be up to date. Regular audits of medical records can help identify gaps in the recording of vaccine status.

5. A key time to record vaccine status and offer MMR vaccination is when patients register with a practice. Ensure that vaccine records are entered on the medical record correctly (including vaccines given overseas) and offer MMR vaccine to patients who are unvaccinated or unsure of their vaccine status.

6. Prime patients with information about MMR vaccination, including who is eligible; and the benefits of vaccination for the individual, their family and society.

7. Use multi-channel communication to inform patients. Consider using a variety of media to inform patients as well as direct contact through text messages, phone calls, emails and letters: posters, leaflets, social media, and the practice’s website. Different people prefer different methods of communication. Partnering with local schools, colleges and universities can also help in contacting patients.

8. Be culturally sensitive, particularly if your practice is located in a diverse area. Use materials that are linguistically and culturally appropriate to cater to diverse populations, especially those who may not be fluent in English or are from different cultural backgrounds. Collaborations with community organisations and voluntary groups can help practices to better reach and communicate with diverse groups of patients; including those least likely to be vaccinated.

9. Provide accessible clinics for MMR vaccination and also offer opportunistic vaccination to patients when they attend appointments at the practice for other reasons. To make it easier for working adults, consider extending clinic hours for vaccinations. Some areas may also offer mobile clinics or clinics in community centres that can further improve access to vaccination.

10. Monitor uptake in each target group. Contact those who have not come forwards for vaccination by text, email or telephone. Discuss the need for vaccination with patients in clinics. Implementing an automated system for sending reminders for upcoming vaccination appointments can be efficient and lead to increased attendance.

11. Some patients will receive MMR vaccines elsewhere in the NHS or overseas. Details of vaccinations at NHS sites should be sent to the practice automatically but this may not always be the case. Contact patients to check their vaccination status by text or email and enter vaccinations on their medical record if given elsewhere. This will improve the data the NHS uses to monitor vaccine uptake and also ensures that patients are not sent unnecessary reminders.

12. Incentivise staff to achieve targets; and work with the patient participation group and other local community groups to increase awareness of the benefits of vaccination and improve vaccine uptake.

13. Develop a way for patients to provide feedback about their vaccination experience. This could be a short survey sent by email or available at the clinic. The feedback can provide valuable insights for improving the programme in the future. Also consider a post-campaign evaluation to understand what worked well and what didn’t. This information can be also help for planning future campaigns.

14.The same principles can be applied to maximise uptake of other vaccination programmes delivered by the practice for both children and adults.

Freedom of Speech in Universities

The balance between free speech and its limitations is a challenging aspect of modern society, including academic environments like universities. In the context of universities, the promotion of free speech is vital to academic freedom and the pursuit of knowledge. Universities are traditionally places where diverse ideas and perspectives can be explored and debated. However, this freedom comes with the responsibility to ensure that speech does not incite violence, promote hate, or harm others.

The legal limits on freedom of speech in societies like the UK are in place to protect individuals and groups from harm, such as laws against hate speech, incitement to violence, and defamation. These laws acknowledge that while the free exchange of ideas is fundamental, there are boundaries necessary for the protection of public order and individual rights.

In addition to these legal limits on freedom of expression, there are also social constraints on what can be said which vary from society to society. These constraints can vary over time and lead to adverse consequences for individuals even if what they say is not illegal.

The discussion around sanctions for universities that limit the rights of students to express their views is part of a broader debate about how universities can create an environment that encourages open dialogue while also maintaining safety and respect for all students. It’s about finding the right balance between allowing free and open discourse and protecting the rights and dignity of all members of the university community.

Hence, the concept of absolute free speech does not exist in practical terms due to necessary legal, social and ethical constraints. The challenge lies in ensuring that these limits are applied in a way that is fair, just, and conducive to a healthy, productive public discourse.

Universities have a responsibility to create an environment where all students feel safe and respected, and where they can learn and grow without fear of harassment or discrimination. This means that universities need to have clear policies on freedom of speech, and they need to be prepared to take action against students who engage in harmful speech.

What is Seasonal Affective Disorder (SAD) and How is it Managed?

At this time of year, I am often asked by patients about Seasonal Affective Disorder (SAD). This is a is a type of low mood or depression that is related to changes in the seasons. It typically begins and ends at about the same times every year. Most people with SAD experience symptoms starting in the Autumn that continue into the winter months.

Symptoms of SAD may include:

– Feeling depressed most of the day, nearly every day
– Losing interest in activities you once enjoyed
– Low energy and fatigue
– Sleep disturbances (oversleeping or insomnia)
– Changes in appetite or weight (often craving for foods high in carbohydrates)
– Feeling sluggish or agitated
– Difficulty concentrating
– Feelings of hopelessness, worthlessness, or guilt

In more severe cases there can also be thoughts of self-harm, death or suicide.

The causes of SAD are not fully understood but are believed to be related to the reduction in sunlight in Autumn and Winter. This decrease in sunlight may disrupt the body’s internal clock and lead to feelings of depression.

Reduced sunlight can also cause a drop in serotonin, a brain chemical (neurotransmitter) that affects mood, and affect the balance of melatonin, which plays a role in sleep patterns and mood.

Patients also ask how can SAD be treated and the symptoms of SAD improved?

– Get regular exercise. Exercise can help to improve your mood and sleep. Aim for at least 30 minutes of moderate-intensity exercise most days of the week.

– Eat a healthy diet. Eating healthy foods can help to boost your mood and energy levels. Aim to eat plenty of fruits, vegetables, and whole grains.

– Get enough sleep. Most adults need around 7-8 hours of sleep per night. However, people with SAD may need more sleep than this.

– Spend time outdoors. Even if it’s cold, try to get outside for at least 30 minutes each day. Getting some sunlight can help to improve your mood and sleep.

– Talk to a doctor or therapist. If you’re struggling to manage your symptoms, talk to your doctor, therapist or local mental health team. They can help you to develop a treatment plan that works for you.

– Self- Referral. Many parts of England allow you to refer yourself to local mental health services without requiring a referral from your doctor.

Should we shift from using ‘junior doctors’ to postgraduate doctors?

In the UK’s National Health Service (NHS), the language we use to describe medical professionals holds significant weight. The term ‘junior doctor,’ a longstanding descriptor for doctors in training or those in their early postgraduate years in the UK, is now being re-evaluated. The British Medical Association (BMA) has highlighted the need for a terminology update to more accurately reflect the expertise and responsibilities of these vital healthcare professionals. Our article in BJGP Open discusses this issue further.

The Need for Change

The term ‘junior doctor’ has been a staple in the UK medical lexicon for decades, but it fails to capture the breadth of experience and skill these doctors possess. These professionals, who may have up to a decade of training, are fully qualified and play a crucial role in patient care, performing a wide range of duties from diagnosis to complex medical procedures. The current term may inadvertently diminish their value and expertise.

A More Accurate Representation

As the roles of these doctors evolve with advancing medicine, so too should the terminology. The proposed shift to ‘postgraduate doctors’ better represents their level of education and training, impacting how they are perceived by patients, colleagues, and the broader public. This change is particularly pertinent in primary care, where these doctors often serve as critical members of the clinical team and are involved in supervisory roles.

Enhancing Recruitment and Job Satisfaction

This rebranding is more than a semantic shift; it’s a move that could influence recruitment into medical specialties, including general practice. At a time when the NHS faces challenges in recruiting for general practice roles, recognizing the perspectives and contributions of this younger generation of doctors is crucial.

Supporting Evidence

A report by Prof Scarlett McNally for Health Education England (HEE) found overwhelming support for moving away from the term ‘junior doctor.’ The majority of respondents, including doctors, patients, and healthcare staff, favoured ‘postgraduate doctors’ as a more appropriate alternative. This change also aligns with the desire for clarity regarding a doctor’s seniority level.

Implications for Patient Care

The term ‘junior doctor’ can inadvertently cause patient anxiety, especially in high-stress situations. Introducing oneself as a ‘doctor’ or ‘postgraduate doctor’ can instil more confidence in patients. Clear designations on name badges and specific introductions can reduce uncertainty and potential bias.

A Collective Effort

The support for this change isn’t limited to the BMA; various surgical and medical royal colleges in the UK have also advocated for moving away from the term ‘junior doctors.’ This collective effort underscores the importance of language in shaping patient perception and trust.

Conclusion

As healthcare evolves, so must our language. The shift from ‘junior doctors’ to ‘postgraduate doctors’ is more than a nominal change; it’s a step towards a more accurate, respectful, and empowering representation of these medical professionals. This change not only recognizes their expertise and contributions but also enhances patient care and trust in the healthcare system. The medical community should actively engage in discussions and work towards implementing this revised designation, reflecting the realities of modern medical practice.

Boosting Vaccine Uptake in Pregnancy: What Works and What Doesn’t

Pregnancy is a time of anticipation and preparation. But it’s also a time when expectant mothers must be vigilant about their health — not just for themselves but for their unborn children as well. Vaccinations against COVID-19, influenza, and pertussis are vital during this period, yet many pregnant women hesitate to get these lifesaving shots. Let’s delve into recent research that sheds light on effective strategies to increase vaccine uptake among pregnant women.

Our study published in the Journal of Travel Medicine reviewed studies from January 2012 to December 2022, following the gold-standard PRISMA guidelines, to identify interventions that successfully increase vaccine uptake in pregnant women. The meta-analysis focused on three key diseases: COVID-19, influenza, and pertussis — all of which pose significant risks to both mother and child.

Key Findings

Out of 2,681 articles, 39 studies were relevant, comprising over 168,000 participants from nine different countries. Interestingly, while 15 of these were randomized controlled trials, the quality of evidence was strong in only 18% of the studies. Here’s what we found:

– For influenza, interventions modestly increased vaccine uptake, but the overall effect was small.

– For pertussis, the data showed no clear benefit from the interventions.

– There were no randomized controlled trials available for COVID-19 vaccine interventions during pregnancy.

The ‘Three Ps’ Approach

The interventions that were examined fell into three categories — patient, provider, and policy-level strategies.

Patient-Level: The most effective strategies at this level involved healthcare professionals giving clear recommendations, supplemented by text reminders and written information. Personalized face-to-face discussions that addressed concerns, debunked myths, and emphasized benefits were particularly effective.

Provider-Level: Educating healthcare professionals about the vaccines’ safety and importance, along with reminders to offer them as part of routine care, made a significant difference.

Policy-Level: Financial incentives, mandatory recording of vaccination data, and ensuring vaccines are readily available were key policy interventions that showed promise.

Conclusions

Our study indicates that while there’s some success in increasing influenza vaccinations, the overall impact of interventions is modest. Pertussis vaccine interventions didn’t show a clear benefit, and data on COVID-19 interventions is lacking.

What’s clear is the pivotal role of healthcare providers in educating and encouraging pregnant women to get vaccinated. There’s also untapped potential in mobile health technologies that could further promote vaccination during pregnancy.

The takeaway message is that a concerted effort combining clear communication, education, and policy support is essential to protect both mothers and their babies from vaccine-preventable diseases. As the medical community continues to explore and implement these interventions, the hope is to see a significant rise in vaccine uptake, ensuring safer pregnancies and healthier babies.

The Next Steps

For healthcare providers, the message is to continue the dialogue with expectant mothers, ensuring they have all the information they need to make informed decisions about vaccinations. For policymakers, the challenge is to create an environment where vaccinations are not just available but are actively and consistently promoted as part of prenatal care. And for expectant mothers, our study underscores the importance of discussing vaccinations with healthcare providers to ensure the healthiest possible start for their children.

Closing Thoughts

Vaccinations during pregnancy aren’t just a personal choice; they’re a public health priority. Our study provides a roadmap for increasing vaccine uptake — a mission that, if successful, could mean the difference between life and death for the most vulnerable among us.

Chickenpox vaccination in the UK

The Joint Committee on Vaccination and Immunisation (JCVI) recommending the inclusion of the chickenpox (varicella) vaccine in the UK’s childhood immunisation schedule is a significant step for public health. This decision aligns the UK with many other countries that have already integrated the chickenpox (varicella) vaccine into their routine childhood immunisation programmes.

The implementation of the chickenpox vaccine on a national scale offers several benefits:

1. Reduction in cases: Widespread vaccination among children has the potential over time to significantly reduce the incidence of chickenpox, a highly contagious disease, among children and the wider community.

2. Prevention of complications: While chickenpox is often mild, it can lead to serious complications such as secondary bacterial infections, pneumonia and encephalitis; and can be particularly severe in immunocompromised individuals. Vaccination will help reduce the risk of these complications.

3. Healthcare burden: By reducing the number of chickenpox cases, the NHS can lower the associated healthcare burden, saving resources, GP consultations, urgent care capacity and hospital beds for other important healthcare needs.

4. Economic impact: Fewer chickenpox cases mean less time off from school for children and work for parents, positively affecting the economy and individual productivity, as well as educational outcomes for children and quality of life for families.

5. Herd immunity: Vaccination contributes to herd immunity, protecting those who are not  vaccinated or at higher risk of complications from chickenpox.

6. Health equity: Bringing the UK’s vaccination programme in line with other countries ensures that children in the UK benefit from the same level of healthcare protection.

The JCVI’s recommendation is based on evidence of the vaccine’s safety and effectiveness, making it a positive addition to the UK’s public health strategy. This decision underscores a commitment to safeguarding children’s health and reducing the impact of preventable diseases through immunisation once the governments in the UK and devolved nations accept the decision and start to implement the recommended vaccination programme.