Blog posts

Identifying naturally occurring communities of NHS primary care providers

Primary Care Networks (PCNs) are a new organisational hierarchy with wide-ranging responsibilities introduced in the National Health Service (NHS) Long Term Plan. The vision is that PCNs should represent ‘natural’ communities of general practices (GP practices) collaborating at scale and covering a geography that fits well with practices, other healthcare providers and local communities. Our study published in BMJ Open aims to identify natural communities of GP practices based on patient registration patterns using Markov Multiscale Community Detection, an unsupervised network-based clustering technique to create catchments for these communities. With PCNs expected to take a role in population health management and with community providers expected to reconfigure around them, it is vital to recognise how PCNs represent their communities. Our method may be used by policymakers to understand the populations and geography shared between networks.

DOI: 10.1136/bmjopen-2019-036504

The primary care response to COVID-19 in England’s National Health Service

In a recent article, I discuss the primary care response to Covid-19 in England. The first case of COVID-19 in England was identified at the end of January 2020. Cases increased during February, and by early March, it became apparent that England faced a large COVID-19 epidemic. This led to the Department of Health and Social Care and NHS England (the bodies that respectively fund and manage the NHS in England) to recommend radical changes to the provision of NHS primary care services.
For most general practices, these changes began to be implemented in the week beginning 16 March 2020. As a first step, general practices switched from the traditional model of face-to-face service provision to one where all patients were initially assessed through a telephone or a video call. Patients were encouraged to register for online booking of these appointments if they had not already done this.
All patients requesting advice spoke first to a health professional, usually general practitioners. The aim was to deal with as many queries as possible by telephone or a video call. Patients who required a face-to-face appointment were booked to be seen in later that day. This ensured that patients were largely managed on the same day they sought medical advice. These changes have resulted in around three-quarters of patients being managed remotely compared to the same time last year when only one-quarter were, with the total volume of primary care activity falling by about 25%.
We have seen rapid changes in primary care in England, but challenges remain, particularly if the number of people with COVID-19 infection increases rapidly and starts to overwhelm the health system, or if second and subsequent waves of infection occur. Other challenges include providing medical care for people who are self-isolating at home because of their age or because of underlying medical problems that increase their risk of complications and death if they contract a COVID-19 infection. There are also problems that will arise from the cutting back of many specialist hospital services, which will have negative effects on health outcomes if restrictions in health services remain in place for a prolonged period.
Overall, primary care in England has responded well to the COVID-19 pandemic, making radical changes to how primary care services are delivered in a very short period of time. Key to allowing this to happen is the commitment by the UK government to support general practices financially to prevent the loss of income that has occurred to primary care practices in countries such as the USA. However, the future will remain challenging for primary care teams in England until such time as a vaccine or effective drug treatment can be found for COVID-19.
Read the full article in the Journal of the Royal Society of Medicine.

Health inequalities: the hidden cost of COVID-19

My article in the Journal of the Royal Society of Medicine discusses the wider impact of COVID-19 on health systems and the potential for changes to health services to increase health inequalities. We report a 44% decrease in emergency department attendances in England in March 2020. We must not overlook the importance of good infection control for outsourced NHS staff such as cleaners, security guards and caterers. They can acquire COVID-19, thereby putting themselves at risk, and transmit COVID-19 to patients and other NHS staff.
Read the full article in the Journal of the Royal Society Medicine.

Protecting healthcare workers during the COVID-19 pandemic

My editorial in the British Journal of General Practice discusses how we can protect healthcare workers during the Covid-19 pandemic. Some of the key steps we can take include:
1. Maximise remote working
2. Implement good infection control
3. Use PPE effectively.
4. Risk assessment for staff based on age and medical history
Too many health and care workers have died and we must take urgent action to protect them. When we protect staff, we also protect patients because we reduce the risk of hospital acquired infection.
Read the full article in the British Journal of General Practice.

Protecting older people from COVID-19: should the United Kingdom start at age 60?

National and global spread of COVID-19 is accelerating. To reduce COVID-19-related hospitalisations, intensive care unit admissions and deaths, we recommend that those aged between 60 and 69 years are particularly stringent when implementing public health measures such as social distancing and personal hygiene. In the absence of government guidance, people in this group can make their own informed decisions on how to minimise their risks of COVID-19 infection. This can include using precautionary measures to reduce the risk of infection in a similar manner to that recommended by the UK government for people aged 70 years and over.

Read the article in the Journal of the Royal Society of Medicine.

DOI: https://doi.org/10.1177/0141076820921107

Improving workplace health in the NHS

As one of the largest organisations in the world, employing around 1.5 million people, and the provider of publicly funded healthcare in the UK, the National Health Service (NHS) should be a role model in workplace health. It should be providing employers with guidance and good practice that can be replicated elsewhere. However, currently the NHS performs poorly on many measures of staff health. For example, sickness absence rates among NHS staff are higher than the average for both the UK public sector and private sector.

The health of NHS staff is a key factor in determining how well the NHS provides healthcare to patients. Improving workplace health and the support available to staff with health problems — such as enabling them to return to work after absence due to sickness — should be priorities for the NHS.

The importance of good working environments in the NHS was emphasised in a 2019 General Medical Council report. The report noted that workplace pressures are associated with risks to patient care and the wellbeing of doctors, leading to “burnout” and poor staff retention and exacerbating shortages of medical professionals in the NHS.

A key message from the report was that the support that doctors received in the workplace from other clinical colleagues and managers was an important factor in determining how well they coped with the pressures of working in the NHS. Doctors at low risk of burnout were more likely to report that they were well supported by their colleagues and were also less likely to be absent because of work related stress.

A healthier NHS workforce would bring substantial benefits for NHS patients and better patient outcomes. NHS workplaces should aim to be centres of excellence for workplace health promotion, setting a positive example and providing case studies, guidance, and support to other public sector and private sector organisations

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

Coronavirus infection: the importance of good personal hygiene in reducing infection risk

The Covid-19 (Coronavirus) infection is spreading more widely. The best way to protect yourself, your family and your work colleagues is through preventive actions such as regular handwashing, using disposable tissues when you cough and sneeze, and staying at home when you are unwell. Remember also not to touch your nose, mouth or eyes unless you have washed your hands recently.

Many of my patients are informing me they are unable to buy hand sanitizer because pharmacies and supermarkets have no stock as people have been buying large amounts because of concerns about coronavirus (Covid-19) infection. Don’t bother buying hand sanitizer. Use soap and warm water instead. Washing your hands with soap and water is usually more effective than using hand sanitizers at removing germs, and is also better at preserving the “good” bacteria on your hands. Soap and water is also a lot cheaper than sanitizer.

Finally, one person has recently died from coronavirus infection in the UK. This has caused some anxiety amongst the public and also generated a lot of media coverage. It’s important to reassure people that:

  • The number of coronavirus cases in the UK is currently low.
  • Most people will recover if they become infected.
  • You can reduce your risk of infection through good personal hygiene such as regular hand-washing.

Case fatality in Covid-19 (Coronavirus) infection

We have seen varying estimates of the case fatality rate from Covid-19 (Coronavirus) infection. The case fatality rate is the percentage (or proportion) of patients with a disease who die. We should be cautious about accepting the estimates that have been published in medical journals as valid because many people will have undiagnosed infections. This is particularly likely in children, who often have mild symptoms (or no symptoms) when they contract a viral infection. Hence, the reported case fatality rates we have seen published in medical journals will overestimate the true death rate. As testing for Covd-19 infection becomes more widespread, we will get better estimates of the true infection rate in the population from the virus, and hence better estimates of the complication rate and death rate from the illness. In England, the new testing programme in people with respiratory tract infections announced by Public Health England will provide some of ths information.

Sepsis: getting the balance right

An editorial published in the BMJ by Paul  Morgan and me discusses the importance of getting the balance right in the diagnosis and treatment of sepsis. Public and professional understanding of sepsis has increased greatly in recent years. This has led to campaigns to diagnose sepsis early in the clinical course of the illness and to start treatment with antibiotics and fluid replacement promptly. Examples include the Survive Sepsis campaign, which led to the creation of the UK Sepsis Trust, and the establishment of the Global Sepsis Alliance and World Sepsis Day. But could this pressure to improve sepsis management be counterproductive and lead to overdiagnosis of sepsis?

doi: https://doi.org/10.1136/bmj.l6700

Impact of GP gatekeeping on quality of care, health outcomes, health care use, and spending

In many health systems, primary care physicians (sometimes referred to as general practitioners or family physicians) regulate access to specialist medical services and investigations. This process is sometimes described as “gatekeeping” and is a response to a shortage of specialists and a need to control healthcare spending. In gatekeeping systems, patients are required to visit a GP or primary care physician to authorise access to specialty care. However, the effectiveness of gatekeeping remains unclear.

In a systematic review published in the British Journal of General Practice, we examined the impact of gatekeeping on areas such as the quality of health care, healthcare spending and use, and health-related and patient-related outcomes.

We found an an association between gatekeeping and better quality of care, especially in terms of preventive care, and appropriate referral for specialty care and investigation. However, we found one study that reported unfavourable outcomes of patients with cancer under gatekeeping.

Gatekeeping resulted in fewer hospitalisations and lower specialist use, but also led to more primary care visits. Gatekeeping may also lead to lower healthcare use and expenditure. Primary care clinicians have conflicting views on gatekeeping, whereas patients are often less satisfied with gatekeeping schemes, preferring health systems where they have direct access to specialists.

As with many areas of health policy, the impact of gatekeeping on key health system metrics needs further investigation to help devise more efficient and equitable health systems that improve health outcomes and lead to high patient satisfaction whilst at the same time, keeping spending on health services at sustainable levels.