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 cost effectiveness analysis is important in public health

Cost-effectiveness analysis (CEA) is a method used in health economics and healthcare planning to compare the costs and benefits of different healthcare interventions. CEA is particularly important in public health because it helps policymakers and healthcare providers to make informed decisions about which interventions to prioritise and invest in.

Vaccination is a good example of why incremental CEA is important. Vaccination programs can be expensive, and policymakers need to know if the benefits of vaccination outweigh the costs. Incremental CEA can help answer this question by comparing the costs and health outcomes of vaccination to other interventions, or to doing nothing at all.

There are many factors that can affect the cost-effectiveness of a public health intervention. These include the cost of the intervention, the effectiveness of the intervention, and the value of the health outcomes that are achieved (such as a reduction in hospital admissions). The cost of an intervention can vary depending on a number of factors, such as the resources that are needed to implement the intervention, the number of people who are affected by the intervention, and the cost of any associated treatment or care.

The effectiveness of an intervention can also vary depending on the characteristics of the population that is being targeted. In general, public health programmes are more cost-effective in people with a higher risk of poor health outcomes. This is why older people are often targeted. By using incremental CEA, policymakers can identify which public health programmes provide the most health benefits for the lowest cost. They can also use this information to determine the optimal allocation of resources and funding to achieve the best population health outcomes.

Additionally, by comparing the cost-effectiveness of different public health strategies, they can make more informed decisions about which interventions to prioritize and invest in, helping to maximize the overall impact of limited public health resources. As well as vaccination, we can also use CEA to look at other public health programme such as screening for cancer, interventions to promote healthy diets and increase physical activity, and programmes to support people to quit smoking.

The covid-19 pandemic three years on

In a recent article in the British Medical Journal, I discuss where we are three years after the start of the Covid-19 pandemic in the UK and what broad comments can we make about the UK’s ongoing response to the pandemic.

The UK is certainly in a better place now than it was in the first year of the pandemic; a period when many people became seriously unwell, resulting in significant pressures on the NHS and a very large number of deaths. One positive step is the creation of the UK Health Security Agency. This begins to address the weaknesses that arose in England’s health protection functions following the abolition of the Health Protection Agency in 2013 and is recognition that the UK needed a government organisation that was focused on health protection. However, the devolved nature of the UK means that some responsibilities for health protection lie with the UK government, while others lie with the national assemblies in Wales, Scotland, and Northern Ireland. This does create scope for a fragmented response to the still-ongoing covid-19 pandemic (and future outbreaks of other infectious diseases); as well as the possibility of political tensions between the UK governments and the national assemblies in the devolved nations as we saw at times during the previous three years.

The UK government now views the worst of the pandemic as being over. The UK was among the first countries to start a vaccination programme against covid-19. Vaccination combined with immunity from prior infection has reduced the severity of illness from covid-19 in the UK with deaths and hospital admissions both now at a much lower level than they were in January 2021. The UK is now highly reliant on vaccination to suppress the impact of covid-19 on our society and its impact on the NHS. Maintaining this protection will probably require regular booster vaccinations for the most vulnerable groups in society, such as the elderly, the immunocompromised, and those with significant long term medical problems. Conversely, routine covid-19 vaccination for people under 50 years of age is likely to stop other than for those who are in a high clinical risk group or who are carers.

Take-up of the first two doses of covid-19 vaccination was very high thanks to the positive attitude to vaccination in the UK population and the rapid mobilisation by the NHS of sites for delivering vaccines. However, the most recent booster campaign carried out in the autumn and winter of 2022-23 saw a much lower uptake of vaccination. Addressing vaccine hesitancy, tackling disinformation, and improving confidence in vaccines will remain key aims for the NHS, health professionals and public health agencies in the UK. The risk of a further wave of serious illness from covid-19 remains, either from declining population immunity or from the emergence of a new variant of SARS-CoV-2 that can bypass pre-existing immunity and cause more serious illness than currently circulating variants. Regular vaccination of the most vulnerable groups will help mitigate these risks, as will covid-19 treatments for the groups at highest of serious illness.

One area that the UK excelled during the pandemic was in the use of data to monitor the epidemiology of covid-19 and the effectiveness of vaccines. The UK also set up a range of research studies that informed the pandemic response not just in the UK, but globally as well. However, much of this data collection and analysis infrastructure is now being dismantled. This will make the UK much more reliant on conventional methods of measuring the impact of a disease as opposed to using data from the new systems—such as the coronavirus (COVID-19) Infection Survey—established over the last three years. It is essential the information systems we have in place continue to provide the data needed to monitor covid-19 trends and rapidly identify any resurgence in covid-19.

The UK has spent considerable sums on managing the pandemic and mitigating its impact on the NHS and the economy. As we move forward into the next phase of pandemic, interventions to manage covid-19 will need to be evaluated through the usual routes used by the NHS; with slower adoption of interventions than we saw earlier in the pandemic—as shown, for example, by NICE refusing to endorse the use of Evusheld. Future pandemic planning will also need to consider the impact of interventions on children. Much of the focus earlier in the pandemic was on protecting older people. But the pandemic also had important impacts on the physical and mental health of children as well as on their educational and social development in the UK and elsewhere. The management of people with post covid-19 syndromes (long covid) also remains challenging with demand far outstripping the supply of services for diagnosis and management.

The NHS in the UK faces many challenges and investment in interventions for managing covid-19 will need to be compared to interventions for managing other health priorities—such as urgent care, general practice, mental health and cancer—to ensure that maximum population benefit is obtained. For example, vaccine booster programmes for covid-19 will need to examine the incremental cost-effectiveness of vaccination in different population groups to identify priority groups for vaccination rather than vaccination being made available to all adults. The era of issuing “blank cheques” for tackling covid-19 is now over and investment for interventions for covid-19 will need to compete with investment in other public health and healthcare services.

How can we improve the quality of data collected in general practice?

The primary purpose of general practice electronic health records (EHRs) is to help staff deliver patient care. In an article published in the British Medical Journal, Lara Shemtob, Thomas Beaney, John Norton and I discuss the need for the general practice staff entering data in electronic health records to be more connected to those using the information in areas such as healthcare planning, research and quality improvement.

Documentation facilitates continuity of care and allows symptoms to be tracked over time. Most information is entered into the electronic record as unstructured free text, particularly during time pressed consultations. Although free text provides a mostly adequate record of what has taken place in clinical encounters, it is less useful than structured data for NHS management, quality improvement, and research. Furthermore, free text cannot be used to populate problem lists, calculate risk scores, or feed into clinical management prompts in electronic records, all of which facilitate delivery of appropriate care to patients.

Creating high quality structured data that can be used for health service planning, quality improvement, or research requires clinical coding systems that are confusing to many clinicians. For example, coding can seem rigid in ascribing concrete labels to symptoms that may be evolving or of diagnostic uncertainty. It is time consuming for staff to process external inputs to the electronic record, such as letters from secondary care, and if this is done by administrators, comprehension of clinical information may be a further barrier to high quality structured data entry.

The content of digital communications such as text messages from patients to clinicians, emails, and e-consultations may also need to be converted to structured data, even if the communication exists in the electronic health record. This all represents additional work for clinicians with seemingly little direct incentive for patients. As frontline clinical staff are usually not involved in the secondary uses of data, such as health service development and planning, they may not consider the extra work a priority.

To maximise the potential of routinely collected data, we need to connect those entering the data with those using them, also incorporating patients as key beneficiaries. This requires adopting a learning health systems approach to improving health outcomes, which involves patients and clinicians working with researchers to deliver evidence based change, and making better use of existing technology to improve standardised data input while delivering care.

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Data from primary care played a key role in the UK’s Covid-19 pandemic response as shown in this slide which uses data from a range of sources – including general practice records – to examine the impact of vaccination on hospital admissions for Covid-19 in England.

Twenty-year trajectories of cardio-metabolic factors among people with type 2 diabetes by dementia status in England

In a study published in the European Journal of Epidemiology, we assessed 20-year retrospective trajectories of cardio-metabolic factors preceding dementia diagnosis among people with type 2 diabetes (T2D).

We identified 227,145 people with T2D aged > 42 years between 1999 and 2018. Annual mean levels of eight routinely measured cardio-metabolic factors were extracted from the Clinical Practice Research Datalink. Multivariable multilevel piecewise and non-piecewise growth curve models assessed retrospective trajectories of cardio-metabolic factors by dementia status from up to 19 years preceding dementia diagnosis (dementia) or last contact with healthcare (no dementia).

23,546 patients developed dementia; mean (SD) follow-up was 10.0 (5.8) years. In the dementia group, mean systolic blood pressure increased 16–19 years before dementia diagnosis compared with patients without dementia, but declined more steeply from 16 years before diagnosis, while diastolic blood pressure generally declined at similar rates. Mean body mass index followed a steeper non-linear decline from 11 years before diagnosis in the dementia group. Mean blood lipid levels (total cholesterol, LDL, HDL) and glycaemic measures (fasting plasma glucose and HbA1c) were generally higher in the dementia group compared with those without dementia and followed similar patterns of change. However, absolute group differences were small. Differences in levels of cardio-metabolic factors were observed up to two decades before dementia diagnosis.

Our findings suggest that a long follow-up is crucial to minimise reverse causation arising from changes in cardio-metabolic factors during preclinical dementia. Future investigations which address associations between cardiometabolic factors and dementia should account for potential non-linear relationships and consider the timeframe when measurements are taken.

Impact of vaccination on Covid-19 hospital admissions in England

Our new article in the Journal of the Royal Society of Medicine examines the impact of vaccination on hospital admissions for Covid-19 in England during 2021. Covid-19 vaccination substantially reduced the risk of hospital admission, particularly in people who received three doses.  We used data over a whole calendar year covering multiple variants of SARS-CoV-2, variable case rates and changing vaccine uptake.

This provides a population-level overview of the impact of vaccination that is not possible from studies over a shorter period. Using primary diagnosis of Covid-19 as the inclusion criteria increases the specificity of our study by excluding those co-incidentally Covid-19 positive but admitted for another reason. We excluded “ghost patients” that can bias the estimates of vaccine effectiveness.

We report a dose-dependent effect of vaccination, as well as waning of the effectiveness of each vaccination dose, highlighting the value of booster vaccinations. Our analysis supports an ongoing programme of booster vaccinations, especially in the elderly and risk groups.

What needs to be done to address staffing shortages in health and social care?

Our new article in the British Journal of General Practice discusses the importance England’s NHS having an effective workforce strategy. Staffing shortages in health and social care are limiting the delivery of services. Interventions to improve the recruitment and retention of staff, along with also improving staff wellbeing, are essential.

Health and social care organisations must invest in understanding what works to recruit and retain staff, and, in the case of general practice, in patient- facing roles. NHS Employers suggests target areas for focus for employing organisations, such as encouraging flexibility and supporting new starters; however, there is a lack of evidence on what is proven to keep people in post, recently highlighted by the Royal College of Anaesthetists concerned about staffing levels within their own specialty.

Financial incentives including pay, taxation, and pensions must be optimised but do not exonerate the need to optimise working conditions. Outcomes of health, wellbeing, and support initiatives such as patient safety, staff turnover, sickness absence, and financial impact should be analysed and shared across organisations. Local and national retention programmes should involve staff, patients, and occupational health. Looking after the workforce in all health and social care settings will improve productivity and staff retention as well as providing safer care for patients.

Arguments for and against user fees for NHS primary care in England

There has been considerable recent debate about charging for GP appointments after comments from two former UK health secretaries, Kenneth Clarke and Sajid Javid, elicited strong responses both for and against user fees. Let’s try to put aside ideology and emotion and look objectively at the evidence and arguments around user fees in NHS primary care.

Debates over NHS user fees are not new. In 1951, Hugh Gaitskell introduced charges for prescriptions, spectacles, and dentures. Aneurin Bevan, minister for labour and architect of the NHS, resigned in protest at this abandonment of the principle of NHS care being free at the point of need. Many developed countries already charge users to access primary care services, often through a flat-rate co-payment. However, there is a lack of evidence about the impact of such fees on access to healthcare, health inequalities, and clinical outcomes. A key study on the impact of user fees in a high income country (the RAND Health Insurance Experiment) is now nearly 40 years old.

User fees should theoretically encourage patients to act prudently and so reduce “unnecessary” or “inappropriate” use of healthcare. Some European countries with user fees for primary care have indeed seen lower rates of healthcare utilisation. But this theory is based on the assumption that patients can safely and effectively distinguish between necessary and unnecessary care. In reality, preventive care and chronic disease management are both likely to decline when fees are in place, with patients often delaying presentation until costly medical crises occur.

Expectations about what the UK NHS should offer are already high among the public, and user fees may further increase expectation of a “return on investment.” Doctors may feel pressure to provide prescriptions and referrals, or carry out investigations, to satisfy patients who have paid to see them. User fees may also result in patients hoarding health problems, with clinicians expected to tackle more health concerns in the typical 10-15 minute appointment in general practice. Flat-rate user fees might also introduce a financial barrier to healthcare access for people with a low income, potentially widening health inequalities.

The highest users of primary care, such as women seeking maternity care, and those aged under 5 or over 65 years, are also among the group that would probably be exempt from user fees. If people with a low income are also exempted from fees, we may see little reduction in GP workload, and only modest additional revenues for the NHS—particularly when offset against the costs of collecting fees, including chasing patients for any unpaid fees.

Wealthier patients, when asked to pay for NHS GP appointments, may opt for private primary care instead, further increasing health inequalities and leading to the fragmentation of care. Such an environment could cause private primary care services to expand, increasing shortages of NHS GPs if more GPs choose to work in the private sector.

The collection of user fees would require new billing and debt collection systems across all NHS general practices. To safeguard vulnerable people it would be necessary to create exemptions, which would reduce revenue and further add to administrative costs. After exemptions, user fees would probably only be collected from a relatively small section of the population. For example, around 90% of NHS primary care prescriptions in England are dispensed free of charge and revenues from prescription charges cover only a small percentage of the actual cost of NHS drugs.

User fees may also lead to false economies if they deter people from accessing primary care when they should, resulting in costly delayed diagnoses (for example, for cancer), or lead people to seek care only for acute problems, deprioritising important preventive and chronic care.

User fees will also be ineffective if they divert costs to other parts of the NHS such as accident and emergency departments or urgent care centres. In the USA, for example, user fees have led to “offsetting” of costs, with increased hospital admissions and use of acute mental health services. Patients may therefore choose to use services that are “free” to the user but expensive to the system, such as emergency care. A coherent policy would require simultaneous setting of fees in related areas of the NHS—for example, charging a fee for attending A&E.

UK residents benefit from a high level of financial protection from the costs of illness. Accustomed to free primary care for many decades, the public is likely to resist such fees strongly. As a result, any political party that advocated NHS user fees may pay a high price at a general election.

Valid arguments exist for and against introducing primary care user fees. User fees are promoted by some commentators as a remedy to current NHS challenges in areas such as funding and workload. Yet primary care workload and NHS deficits are also symptoms of deeper problems, such as shortages of clinical staff and reactive, fragmented care. Consequently, user fees by themselves won’t be the solution to problems that have proven intractable for the NHS to solve.

We do, however, need to look at what services we expect NHS general practices to provide and how we fund these services. This will include reviewing the current employment models of NHS GPs. If governments in the UK do not want to fund NHS GP services adequately, user fees of some kind (perhaps for “add-on” but not for core primary care services) or two-tier primary healthcare may be inevitable outcomes.

Source: Azeem Majeed. Let’s look dispassionately at the arguments for and against user fees for NHS primary care in England. https://www.bmj.com/content/380/bmj.p303

Human monkeypox: diagnosis and management

On 23 July 2022, the World Health Organisation (WHO) declared monkeypox a public health emergency of international concern. By 15 December, over 82 500 confirmed cases of human monkeypox across 110 countries had been identified, with 98% of cases emerging in 103 non-endemic countries. Notably, most patients present without clear epidemiological links and non-specific clinical characteristics. We offer an overview of human monkeypox and of the assessment, diagnosis, and management of confirmed cases and at-risk patients based primarily on guidance from the WHO and the UK Health Security Agency (UKHSA).

What is monkeypox?

The monkeypox virus is a zoonotic orthopoxvirus related to the variola virus that causes smallpox. Its main reservoirs are rodents, apes, and monkeys. It was first described in humans in 1970 in the Democratic Republic of Congo (DRC). The following 11 countries have historically reported cases of monkeypox (that is, considered endemic for monkeypox virus): Benin, Cameroon, Central African Republic, Congo, Côte d’Ivoire, DRC, Gabon, Liberia, Nigeria, Sierra Leone, and South Sudan. However, there are insufficient data to delineate the differences between endemic and non-endemic regions. Further, the mode of transmission, presentation, and management during the current outbreak is similar in all regions.

Key management points

  • Consider coinfections with monkeypox and other sexually transmitted infections among patients presenting with an acute rash or skin lesions and systemic symptoms
  • While it is safe to manage monkeypox patients virtually, they may need advice to maintain infection control measures and interventions to manage complications
  • A specialist infectious disease unit with access to novel antivirals such as tecovirimat and cidofovir should manage high risk patients
  • Healthcare workers should be aware of the stigma surrounding monkeypox, which may result in reduced health-seeking behaviours; healthcare staff should screen patients sensitively, using inclusive language to avoid alienating patients

Read more in our article in the British Medical Journal.

Uptake of influenza vaccination in pregnancy

Our study published today in the British Journal of General Practice shows how the uptake of flu vaccination in pregnancy varies with age, ethnicity and socio-economic deprivation.

Pregnant women are at an increased risk from influenza (flu), yet uptake of  Seasonal influenza vaccination (SIV) during pregnancy remains low, despite increases since 2010.

Getting the flu vaccine when pregnant is important, because it reduces the risk of severe disease, complications and adverse outcomes for both mother and child such as pre-term birth. However, uptake was lower among women living in more deprived areas, women who were younger or older than average, Black women and those with undocumented ethnicity.

Although the flu vaccine is safe and recommended for pregnant women, misconceptions about safety play a role in pregnant women not being vaccinated and flu vaccination levels among pregnant women are suboptimal worldwide.

In the UK, since 2010, the Joint Committee on Vaccination and Immunisation (JCVI) has recommended that pregnant women get the flu vaccine to provide protection during the winter flu season. Despite these recommendations, data from Public Health England (now the YK Health Security Agency) showed that in 2020-21, fewer than half of pregnant women were vaccinated.

Previous studies of influenza vaccine uptake during pregnancy have either used data from a single care provider, or from surveys. Our retrospective cohort study looked at 450,000 pregnancies among 260,000 women in North West London, over a ten year period. By applying statistical models to data on women’s age, ethnicity, health conditions and socio-economic deprivation, we were able to identify groups with lower uptake of the flu vaccine.

Misconceptions about the safety and efficacy of antenatal vaccinations play a role in pregnant women being unvaccinated, while recommendation by health professionals improves uptake. To ensure access to vaccines, for high uptake among pregnant women, strong primary care systems are needed and targeted approaches are recommended to reducing inequalities in access to vaccination and should focus on women of Black ethnicity, younger and older women, and women living in deprived areas.

Update for Primary Care Clinical Team 19 January 2023

1. Covid-19 statistics update

After a peak in December, Covid-19 cases, hospital admissions and deaths have begun to decline in January 2023. We are though likely to see further waves of infection later in the year.

2. Covid-19 vaccine boosters

Uptake of Covid-19 boosters has plateaued at a lower level than we hoped for. In England, around 64.4% of people aged 50 and over have received a booster in the current campaign. In Lambeth, only 40% of people aged 50 and over have received a Covid-19 booster, well below the national average. Pleas encourage patients to attend for a booster if they are eligible.

3. Covid-19 treatments

Some people at highest risk of becoming seriously ill from COVID-19 are eligible for antiviral treatments on the NHS. These include some patients with cancer, blood conditions, kidney disease, liver disease and autoimmune conditions, among others.  GP reception staff must arrange an appointment with the clinical team if a patient calls and says they are eligible for these treatments, have tested positive for COVID-19 and have not been contacted about treatment.

My view is that the NHS England treatment pathway is flawed. Asking patients to contact their general practice delays the start of treatment and adds to GP workload. Patients should have been asked to contact their local CMDU directly if they have not been contacted about treatment after a positive Covid-19 test. Any failure by the local CMDU to contact a patient should be seen as an SEA.

 4. Influenza

The latest UKHSA report shows that influenza admissions in London have started to fall from their peak in February. See recent Evening Standard article. https://www.standard.co.uk/news/london/london-past-peak-flu-wave-nhs-azeem-majeed-b1053535.html

We were expecting a larger flu wave in the Winter of 2022-23 because of the greater social missing this winter and the low levels of flu over the previous 2 years.

5.  NHS pressures

The NHS in England has experienced exceptionally high pressures in recent weeks, leading to the Prime Minister holding an emergency NHS summit on Saturday 7 January. We await the outcome of the summit. Strike action is adding to NHS pressures. We need to consider a team how we can support our patients and manage workload.