Blog posts

Impact of COVID-19 on primary care contacts with children and young people in England

During the COVID-19 pandemic, health systems globally shifted towards treating COVID-19 infection in adults and minimising use of health services for other patients, including children and young people (CYP), who were less susceptible to severe COVID-19. In March 2020, the NHS recommended remote triaging before any face-to-face contact to reduce infection risk.

The UK Government announced a nationwide lockdown in England from 23 March 2020, and the public was advised to stay at home to limit transmission of COVID-19 and avoid strain on health resources. GPs were asked to prioritise consultations for urgent and serious conditions, and suspend routine appointments for planned or preventive care.

Children’s access to primary care is highly sensitive to health system changes. We examined the impact of COVID-19 on GP contacts with children and young people (CYP) in England. We used a longitudinal trends analysis was undertaken using electronic health records from the Clinical Practice Research Datalink (CPRD) database.

GP contacts fell 41% during the first lockdown compared with previous years. Children aged 1–14 years had greater falls in total contacts (≥50%) compared with infants and those aged 15–24 years. Face-to-face contacts fell by 88%, with the greatest falls occurring among children aged 1–14 years (>90%). Remote contacts more than doubled, increasing most in infants (over 2.5-fold). Total contacts for respiratory illnesses fell by 74% whereas contacts for common non-transmissible conditions shifted largely to remote contacts, mitigating the total fall (31%).

In conclusion, CYP’s contact with GPs fell, particularly for face-to-face assessments. This may be explained by a lower incidence of respiratory illnesses because of fewer social contacts; changing health-seeking behaviour; or a combination of both. The large shift to remote contacts mitigated total falls in contacts for some age groups and for common non-transmissible conditions.

The study can be read in the British Journal of General Practice.

Let patients self-refer to lifestyle management services

Recent draft guidance from NICE gives a much bigger role to exercise and weight loss in people with osteoarthritis, and painkillers such as paracetamol and strong opioids not advised.

I agree that the aims of the new draft NICE guidance on the management of osteoarthritis in primary care are good but the problem will be in providing patients with access to suitable lifestyle and exercise programmes. In many parts of England, these services are either not currently in place or have very limited capacity. As well as putting in place services with sufficient capacity, we also need to ensure there is equitable access to them, based on clinical need. We know from prior experience that it is more affluent and better educated patients who are more likely to take up these kind of lifestyle and exercise interventions.

We also need to simplify clinical pathways and allow patients to refer themselves directly to services without requiring a referral from a GP. This will improve the speed of access to these services for patients and reduce the demands on already over-stretched GP services.

A version of this blog was first published in the British Medical Journal.

Long term implications of Covid-19 in pregnancy

An article published in the BMJ by Allyah Abbas-Hanif, Neena Modi and myself discusses the long term implications of Covid-19 in pregnancy. Covid-19 in pregnancy increases the risk of severe complications for both mother and baby. The long term implications are unknown, but emerging signals warn of substantial public health threats. To counter high vaccine hesitancy in pregnancy we must end the default exclusion of pregnant women from the rigorous regulated drug development process and implement systematic, long term, population-wide surveillance of infected and non-infected people.

The full article can be read in the British Medical Journal.

The future of the Covid-19 pandemic in the UK – the essential role for vaccination

Thanks to Covid-19 vaccination, we have seen a substantial weakening of the link between Covid-19 infections and hospitalisations / deaths in the UK. But we don’t yet know how well this protection from serious illness and death will persist in the longer-term. We are also seeing “vaccine fatigue” set in with many people not keen on booster vaccines.

For the UK, the future challenges will include determining how frequently and in what groups Covid-19 booster vaccines are needed; ensuring a high take-up of vaccinations in all eligible groups; and having vaccines that are updated when necessary to protect against new variants. We have already had one additional booster vaccination programme in the UK this year; which targeted people 75 and over, residents of care homes, and people who are immunocompromised. A larger booster programme is planned for later this year that will target a wider range of people, including NHS staff.

Although some people are very optimistic about the future because of the recent decline in the number of Covid-19 cases, hospitalisations and deaths in the UK, this optimism does depend on maintaining high levels of Covid-19 immunity in the population. This won’t be easy and we will see some areas of the UK and some population groups with low take-up of booster vaccines. We therefore need to ensure that we have a strong vaccine delivery system in place that can work with local communities to ensure a high-take up of vaccination – particularly in the most clinically vulnerable groups at highest risk of serious illness and death.

Other Covid-19 control measures are also important and can be implemented when necessary, but ultimately it is vaccination that will allow UK society to function normally rather than these other measures.

Let’s keep cool about anxiety-inducing Monkeypox

Earlier this month, a case of Monkeypox was reported in London, followed by reports of further cases in the UK and in many other countries. Understandably, people are anxious whenever an outbreak of an unusual infectious disease occurs, likely more so because of their experiences during the Covid-19 pandemic. Although we need to take the disease seriously, Monkeypox is much less of a threat to global health than Covid-19 and won’t have the same impact on societies or lead to the type of control measures we have seen for Covid-19 over the past two years.

The virus that causes Monkeypox is found primarily in small animals, like rodents, in parts of West and Central Africa – but was first identified in monkeys (hence the name). It can sometimes spread to humans and because of international travel, then spread to other parts of the world. But unlike Covid-19, which is easily transmissible and has caused huge waves of infection globally, Monkeypox spreads much more slowly, requiring close contact with an infected person or animal to spread.

Monkeypox outbreaks can generally be contained through conventional public health measures – like identifying and isolating cases early on, tracing contacts to identify people who are at risk of infection, and good infection control practices when dealing with people who are infected. We know that smallpox vaccines also provides some protection against infection and can be used if necessary in health care workers or in close contacts to reduce their risk of becoming infected. However, use of vaccination will be very limited and we won’t see it used widely in the UK.

Our public health agencies are well-placed to manage the Monkeypox outbreak in the UK. We now have much more experience in areas such as contact tracing and in isolating people with infections than we did before the Covid-19 pandemic. Although we will continue to see cases of Monkeypox in the UK and elsewhere, our public health system has the capacity to limit the outbreak and prevent it from having a major effect on our society.

The Monkeypox outbreak does however reinforce the need for the UK to maintain a strong infection control system so that we are prepared to deal with this and any future infectious diseases that may enter the country. Finally, although people should not become unduly anxious and have a very low risk of coming into contact with a person who has Monkeypox, everyone should remain vigilant and seek medical advice if they become unwell and develop an unusual skin rash.

A version of this article was first published in the Evening Standard.

General practitioner perceptions of using virtual primary care during the COVID-19 pandemic

Whether it be a simple telephone call or more sophisticated video conferencing systems, virtual care tools have been in use in primary care settings worldwide in one form or another throughout the past two decades. Over time, these tools have grown in availability, matured in their capabilities, but played a largely supportive role as an alternative option to traditional face-to-face consultations. This all changed in early 2020 with the onset of the COVID_19 pandemic.

The COVID-19 pandemic presented a unique opportunity globally which put virtual care tools at the forefront of primary care delivery. The need for social distancing to limit disease transmission resulted in virtual care tools becoming the primary means with which to continue providing primary care services. Hence, our study’s goal was to capture the spectrum of GP experiences using virtual care tools during the initial months of the pandemic so as to better understand the perceived benefits and challenges, and explore what changes are needed to allow them to reach their fullest potential.

We carried out a global study to investigate this further, published in the journal PLOS Digital Health. We received 1,605 responses from 20 countries globally. Our results demonstrated that virtual care tools were beneficial in limiting COVID-19 transmission, improved convenience when communicating with patients, and encouraged the further adoption of virtual care tools in primary care. Challenges included patients’ preferences for face-to-face consultations, digital exclusion of certain populations, diagnostic challenges associated with the inability to perform physical examinations, and their general unsuitability for certain types of consultations. Practical challenges such as higher workloads, payment issues, and technical difficulties were also reported.

Learning from this global natural experiment is critical to both updating existing and introducing new health technology policies concerning virtual primary care. Doing so will be imperative to supporting and promoting the better use of these novel technologies in our evolving healthcare milieu.

DOI: https://doi.org/10.1371/journal.pdig.0000029

Understanding Allergy – by Dr Sophie Farooque

In this concise guide, Dr Sophie Farooque – a Consultant in Allergy at St. Mary’s Hospital in London and one of the UK’s leading experts on the treatment of allergic disorders – gives an excellent overview of allergies that will be a very useful guide for the public and also for health professionals.

Allergic disorders have increased substantially in prevalence in recent decades. This is shown in our personal experience as well as by research on the epidemiology of allergic disorders. When I was in school, problems such as hay fever and food allergy were all uncommon in my classmates. This in contrast to now, when many families will have a member who suffers from an allergic disorder. In milder cases, these disorders can be irritating and reduce people’s quality of life. But in more severe cases, they can lead to hospitalisation and sometimes even to death.

Hence, some knowledge of allergies and how they can be managed is very helpful to families who have a member who suffers from an allergy; and can improve their quality of life, as well as allowing them to make better use of NHS services for allergy, whether these are received from general practices or specialist allergy clinics. It is a sad fact that the provision of specialist allergy services by the NHS is well below the need for them, leading to many families and allergy sufferers relying on self-management or on advice from their general practitioners.

In her book, Dr Sophie Farooque covers the most common allergic disorders – such as allergic rhinitis, food allergy, and drug allergies; as well as anaphylaxis, a potentially life-threatening condition. She also discusses “red herrings”; problems that people think are due to an allergy but which in fact have another cause. She also gives very useful advice on self-management and on when medication would be beneficial.

A better understanding of allergies and their treatment is essential for many people and I highly recommend this very readable book for anyone who wants to learn more about the topic and manage their allergies better or improve the treatment of allergies in their children.

Understanding Allergy is published as part of the Penguin Life Experts series and is available from Amazon and other book sellers.

Ethnic disparities in the uptake of colorectal cancer screening

Colorectal cancer is one of the most common cancers and most common cause of cancer deaths worldwide. Despite the availability of screening, disparities in survival from colorectal continue in certain ethnic minority groups. This may, in part, be secondary to low take-up of bowel cancer screening. Different ethnic groups may have different cultural and health beliefs, different levels of education, understanding and acculturation that negatively impacts upon their use of faecal testing and endoscopic procedures.

In a systematic review published in the journal Perspectives in Public Health, we examined studies that had investigated ethnic differences in the uptake of colorectal cancer screening.

We found that disparities in colorectal cancer screening are multifactorial and complex in their origin and that ethnicity plays an important role. Although seemingly intuitive, this is the first systematic review that summarises the association between uptake of screening in specific ethnic groups and which highlights the presence of significant variations in ethnicity classification globally.

Further consistent international research is required to understand why specific ethnic groups are less likely to take up colorectal cancer screening to help in the development of more tailored public health messaging to improve screening rates and to reduce disparities in health outcomes.

DOI: https://doi.org/10.1177%2F17579139221093153

Clinical vignettes in benchmarking the performance of online symptom checkers

In the USA, over one-third of adults self-diagnose their conditions using the internet, including queries about urgent (ie, chest pain) and non-urgent (ie, headache) symptoms. The main issue with self-diagnosing using websites such as Google and Yahoo is that user may get confusing or inaccurate information, and in the case of urgent symptoms, the user may not be aware of the need to seek emergency care. In recent years, various online symptom checkers (OSCs) based on algorithms or artificial intelligence (AI) have emerged to fill this gap

Online symptom checkers are calculators that ask users to input details about their symptoms of sickness, along with personal information such as gender and age. Using algorithms or AI, the symptom checkers propose a range of conditions that fit the symptoms the user experiences. Developers promote these digital tools as a way of saving time for patients, reducing anxiety and giving patients the opportunity to take control of their own health.

The diagnostic function of online symptom checkers is aimed at educating users on the range of possible conditions that may fit their symptoms. Further to presenting a condition outcome and giving the users a triage recommendation that prioritises their health needs, the triage function of online symptom checkers guides users on whether they should self-care for the condition they are describing or whether they should seek professional healthcare support.3 This added functionality could vastly enhance the usefulness of Online symptom checkers by alerting people about when they need to seek emergency support or seek non-emergency care for common or self-limiting conditions.

In a study published in the journal BMJ Open, we assessed the suitability of vignettes in benchmarking the performance of online symptom checkers. Our approach included providing the vignettes to an independent panel of single-blinded physicians to arrive at an alternative set of diagnostic and triage solutions. The secondary aim was to benchmark the safety of a popular online symptom checkers (Healthily) by measuring the extent that it provided the correct diagnosis and triage solutions to a standardised set of vignettes as defined by a panel of physicians.

We found significant variability of medical opinion depending on which group of GPs considered the vignette script, whereas consolidating the output of two independent GP roundtables (one from RCGP and another panel of panel of independent GPs) resulted in a more refined third iteration (the consolidated standard) which more accurately included the ‘correct’ diagnostic and triage solutions conferred by the vignette script. This was demonstrated by the significant extent that the performance of online symptom checkers improved when benchmarked between the original and final consolidated standards.

The different qualities of the diagnostic and triage solutions between iterative standards suggest that vignettes are not an ideal tool for benchmarking the accuracy of online symptom checkers, since performance will always be related to the nature and order of the diagnostic and triage solutions which we have shown can differ significantly depending on the approach and levels of input from independent physicians. By extension, it is reasonable to propose that any consolidated standard for any vignette can always be improved by including a wider range of medical opinion until saturation is reached and a final consensus emerges.

The inherent limitations of clinical vignettes render them largely unsuitable for benchmarking the performance of popular online symptom checkers because the diagnosis and triage solutions assigned to each vignette script are amenable to change pending the deliberations of an independent panel of physicians. Although online symptom checkers are already working at a safe level of probable risk, further work is recommended to cross-validate the performance of online symptom checkers against real-world test case scenarios using real patient stories and interactions with GPs as opposed to using artificial vignettes only which will always be the single most important limitation to any cross-validation study.

A Clinician-Assisted Digital Cognitive Behavioural Therapy Intervention for Smoking Cessation

In a study published in the journal Nicotine and Tobacco Research, we evaluated the secondary effectiveness outcomes for Quit Genius, a digital clinician-assisted cognitive behavioural therapy (CBT) intervention for smoking cessation.

Adult smokers (N=556) were randomly assigned to Quit Genius (n=277), a digital, clinician-assisted CBT intervention or Very Brief Advice (VBA) to stop smoking, an evidence-based, 30-second intervention designed to facilitate quit attempts, coupled with referral to a cessation service (n=279). Participants were offered combination nicotine replacement therapy (patches and gum) tailored to individual nicotine dependence. Analyses (N=530), by intention-to-treat, compared Quit Genius and VBA at 4, 26, and 52 weeks post-quit date.

The primary outcome was self-reported seven-day point prevalence abstinence at 4 weeks post-quit date. Consecutive seven-day point-prevalence abstinence, defined as abstinent at two or more consecutive timepoints, was examined at weeks 26 and 52 to indicate long-term effectiveness. Abstinence was verified using a random sample of participants with carbon monoxide breath testing of <5 parts per million (n=280).

Self-reported consecutive seven-day point prevalence abstinence at weeks 26 and 52 for Quit Genius was 27.2% and 22.6% respectively, compared to VBA which was 16.6% and 13.2% (RR=1.70,95% CI,1.22-2.37;p=0.003, 26 weeks; RR=1.71,95% CI,1.17-2.50; p=0.005, 52 weeks). Biochemically verified abstinence was significantly different at 26- (p=0.03) but not 52 weeks (p=0.16). Quit Genius participants were more likely to remain abstinent than those who received VBA (RR=1.71,95% CI 1.17-2.50;p=0.005).

This study provides secondary evidence for the long-term effectiveness of Quit Genius in comparison with VBA. Future trials of digital interventions without clinician support and comparisons with active treatment are needed.

The long-term effectiveness of clinician-assisted digital smoking cessation interventions has not been well-studied. This study established the long-term effectiveness of an extended CBT-based intervention; results may inform implementation of scalable approaches to smoking cessation in the health system.

DOI: https://doi.org/10.1093/ntr/ntac113