Blog posts

Do callers follow the advice given by NHS 111?

The National Health Service (NHS) 111 helpline was set up to improve access to urgent care in England, efficiency and cost-effectiveness of first-contact health services. Following trusted, authoritative advice is crucial for improved clinical outcomes. In paper published in the journal PLOS ONE, we examined patient and call-related characteristics associated with compliance with advice given in NHS 111 calls.

The importance of health interactions that are not face-to-face has recently been highlighted by COVID-19 pandemic. In this retrospective cohort study, NHS 111 call records were linked to urgent and emergency care services data. We analysed data of 3,864,362 calls made between October 2013 and September 2017 relating to 1,964,726 callers across London. A multiple logistic regression was used to investigate associations between compliance with advice given and patient and call characteristics.

Caller’s action is ‘compliant with advice given if first subsequent service interaction following contact with NHS 111 is consistent with advice given. We found that most calls were made by women (58%), adults aged 30–59 years (33%) and people in the white ethnic category (36%). The most common advice was for caller to contact their General Practitioner (GP) or other local services (18.2%) with varying times scales. Overall, callers followed advice given in 49% of calls.

Compliance with triage advice was more likely in calls for children aged <16 years, women, those from Asian/Asian British ethnicity, and calls made out of hours. The highest compliance was among callers advised to self-care without the need to contact any other healthcare service.

This is one of the largest studies to describe pathway adherence following telephone advice and associated clinical and demographic features. These results could inform attempts to improve caller compliance with advice given by NHS 111, and as the NHS moves to more hybrid way of working, the lessons from this study are key to the development of remote healthcare services going forward.

DOI: https://doi.org/10.1371/journal.pone.0267052

Defining the determinants of vaccine uptake and under-vaccination in migrant populations in Europe

Our new article in Lancet Infectious Diseases discusses why some migrants in Europe are at risk of under-immunisation and show lower vaccination uptake for routine and COVID-19 vaccines. Addressing this issue is critical if we are to address vaccination inequities and meet the goals of WHO’s new Immunisation Agenda 2030.

We carried out a systematic review exploring barriers and facilitators of vaccine uptake (categorised using the 5As taxonomy: access, awareness, affordability, acceptance, activation) and sociodemographic determinants of under-vaccination among migrants in the EU and European Economic Area, the UK, and Switzerland.

We identified multiple access barriers—including language, literacy, and communication barriers, practical and legal barriers to accessing and delivering vaccination services, and service barriers such as lack of specific guidelines and knowledge of health-care professionals—for key vaccines including measles-mumps-rubella, diphtheria-pertussis-tetanus, human papillomavirus, influenza, polio, and COVID-19 vaccines.

Acceptance barriers were mostly reported in eastern European and Muslim migrants for human papillomavirus, measles, and influenza vaccines. We identified 23 significant determinants of under-vaccination in migrants, including African origin, recent migration, and being a refugee or asylum seeker.

We did not identify a strong overall association with gender or age. Tailored vaccination messaging, community outreach, and behavioural nudges facilitated uptake. Migrants’ barriers to accessing health care are already well documented, and this Review confirms their role in limiting vaccine uptake.

These findings hold immediate relevance to strengthening vaccination programmes in high-income countries, including for COVID-19, and suggest that tailored, culturally sensitive, and evidence-informed strategies, unambiguous public health messaging, and health system strengthening are needed to address access and acceptance barriers to vaccination in migrants and create opportunities and pathways for offering catch-up vaccinations to migrants.

DOI: https://doi.org/10.1016/S1473-3099(22)00066-4

Depression and unplanned secondary healthcare use in people with multimorbidity

Multimorbidity, the co-occurrence of two or more chronic conditions, is increasing in prevalence and affecting approximately a third of all adults globally. In the UK, the prevalence of individuals with four or more long-term conditions is projected to increase to 17% by 2035, compared to 9.8% in 2015. Approximately two thirds of this population will have a mental illness such as depression , which is in turn strongly associated with the incidence of a multitude of long-term conditions.

As the number of physical conditions a person increases, the odds of having a mental health disorder increase by almost double for one condition, and six times for more than five conditions. The presence of a mental health comorbidity such as depression is associated with poorer clinical outcomes and quality of life, compared to individuals with physical conditions only.

In an article published in the journal PLOS ONE, we summarised the current evidence on the association between depression and unplanned secondary healthcare use among patients with multimorbidity. To our knowledge, the literature is limited on specifically depression-related multimorbidity clusters, namely different combinations of comorbidities, or specific patient characteristics and the subsequent effect on unplanned secondary healthcare use. Therefore, this review also aimed to explore the effect of the types of comorbidities and if available, different clusters of comorbidities, and sociodemographic predictors of unplanned secondary healthcare among patients with both multimorbidity and depression.

We found that presence of depression increases the likelihood of emergency hospital admissions and readmissions in patients with multimorbidity. This association holds across a range of long-term conditions characterising multimorbidity in various countries, settings and samples. Depression also predicted increased emergency department visits in most of the studies reporting on this outcome. Moreover, the greater the severity of depression, the greater the risk of emergency hospital admissions and emergency department visits.

Patients with co-occurring depression with cancer, COPD, and asthma showed some of the greatest magnitudes of risk of unplanned secondary healthcare use. Being female, of older age and having a greater number of long-term conditions were other predictors of unplanned secondary healthcare use.

DOI: https://doi.org/10.1371/journal.pone.0266605

Data from the NHS is playing a key role in guiding vaccination policies globally

Throughout the pandemic, the UK’s covid-19 data systems have been guiding global as well as local policies. The well-established health information systems combined with the more recently established National Immunisation Management System in England provided timely information on infections, emergence of new variants, and the value of different interventions. But one of the most important contributions from the UK came from the ability to rapidly track vaccine effectiveness.

Vaccination is the best method for societies to reduce the severity of illness and number of deaths from covid-19; and to start to return to a more normal way of living, working, and studying.[1] But vaccination programmes need to be evidence-based, so that vaccines and healthcare resources are used appropriately, and there is equitable vaccine delivery. The covid-19 pandemic has shown the importance of data from medical records and the National Immunisation Management System in guiding national vaccination policies. Clinical trials can provide initial data on the efficacy and safety of vaccines. However, because of their relatively small size and short duration of follow-up, they cannot provide longer-term data on vaccine effectiveness or on rare adverse events.[2] Furthermore, because covid-19 vaccines were designed to target the original strain of SARS-CoV-2, the trials are also unable to provide data on protection against new variants that emerged after the trials were completed. Nor were they able to provide data on the need for booster doses of vaccines to maintain protection from serious illness and death.

Clinical trials are also generally unable to provide data on smaller subgroups of the population such as people who are immunocompromised; or how different vaccines compare in their long-term safety and effectiveness. This data has to largely come from national immunisation systems and from medical records, as does data on vaccine uptake in different groups of the population. These are areas where the UK has excelled during the covid-19 pandemic in work led by government organisations such as the UK Health Security Agency and the UK Office for National Statistics.

In England, the UK Health Security Agency has assessed vaccine effectiveness against symptomatic covid-19 infection using community testing data linked to vaccination data from the National Immunisation Management System (NIMS); with further linkage to data from electronic NHS secondary care datasets;  sequencing and genomics data; travel information; and mortality records. These data have allowed analysis of how well covid-19 vaccines protect against outcomes such as hospitalisation and death as well as against symptomatic infection during the course of the pandemic.[3] With the linkage of secondary care datasets and NIMS data, it has also allowed for timely epidemiological safety signal assessments to be rapidly carried out in response to passive reports of adverse events after vaccination from the MHRA yellow card system. The large size of the English population allows for more precise estimation of these effects; something that is not always possible in data from countries with smaller health systems. Data from the UK also allowed identification of people at highest risk from the complications of covid-19, which helped in deciding which groups would be prioritised for vaccination. UK data also allowed the tracking of breakthrough infections following vaccination better than any other country; and confirmed that delaying the second dose of vaccine was likely to lead to better protection from serious illness.

Most recently, the data has allowed analysis of how well vaccines protect against new variants of SARS-CoV-2 such delta and omicron. The latest data confirm that three doses of vaccines provide good protection from hospitalisation and death from an omicron infection; but that the level of protection is not as high as against the delta variant that was previously predominant in many parts of the world. [4] Protection against infection is also less against newer variants than against the original strain of SARS-CoV-2, which meant that breakthrough infections in vaccinated people were common, particularly at times when community infection rates are high.[4] The data also show that longer-term protection is better with the mRNA vaccines in use in the UK (Pfizer-BioNTech and Moderna) than with the AstraZeneca viral vector vaccine. Ongoing work will show how well this protection from serious illness and death is maintained; and whether further booster doses may be needed in the population more widely after the implementation of a fourth dose in older people and the clinically vulnerable.[5] In addition, epidemiological assessments of safety signals will continue to support and maintain confidence in the covid-19 vaccine programme.

Other data can be linked to the NIMS to allow estimation of vaccine uptake by age group, area of England and by ethnic group. This has proved essential in identifying population groups and geographical areas with lower than average vaccine uptake. For example, the data has shown that vaccine uptake is generally lower in younger age groups than among older people; and lower in large, urban areas such as London than in other parts of England.[6] The development of a public-facing “data dashboard” has allowed easy viewing of this data at national, local and regional level; thereby supporting public health teams to identify areas and communities with lower vaccine uptake.[7]

Looking forward, it is important that we maintain our data collection, linkage, analysis and publication abilities for the longer-term.[8] Although we must now all learn to live with covid-19, SARS-CoV-2 will still pose a threat to global health for some time, especially if new escape variants emerge.[9] Furthermore, with population-level immunity after vaccination waning and covid-19 control measures ending, there is a risk that later in the year we may see a surge in infections in the UK and elsewhere; in recent weeks, we have already seen an increase in covid-19 infections and hospital admissions in the UK. In addition, changes in testing behaviour and guidance may affect how vaccine effectiveness is monitored in the future. The data systems, scope for data linkage, and the analytical capacity in the UK will prove essential in tackling the long-term threat to global public health from covid-19; and lessons from the UK’s data systems should continue to be shared with the rest of the world to support the global response to covid-19.[10]

Azeem Majeed, Elise Tessier, Julia Stowe, Ali Mokdad

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

DOI: https://doi.org/10.1136/bmj.o839 

References

  1. Majeed A, Molokhia M. Vaccinating the UK against covid-19. BMJ. 2020 Nov 30;371:m4654. doi: 10.1136/bmj.m4654.
  2. Majeed A, Papaluca M, Molokhia M. Assessing the long-term safety and efficacy of COVID-19 vaccines. Journal of the Royal Society of Medicine. 2021;114(7):337-340.
  3. Monitoring reports of the effectiveness of COVID-19 vaccination.https://www.gov.uk/guidance/monitoring-reports-of-the-effectiveness-of-covid-19-vaccination
  4. Andrews N, Stowe J, Kirsebom F, et al. Covid-19 Vaccine Effectiveness against the Omicron (B.1.1.529) Variant. N Engl J Med. 2022 Mar 2. doi: 10.1056/NEJMoa2119451.
  5. Walker P, David N. UK: over-75s and vulnerable people to be offered additional Covid booster jab.https://www.theguardian.com/society/2022/feb/21/uk-older-vulnerable-people-to-be-offered-covid-booster-vaccine
  6. Office for National Statistics. Coronavirus (COVID-19) latest insights: Vaccines.https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronaviruscovid19latestinsights/vaccines
  7. Official UK government website for data and insights on coronavirus (COVID-19).https://coronavirus.data.gov.uk/
  8. Tapper J. Dismay as funding for UK’s ‘world-beating’ Covid trackers is axed.https://www.theguardian.com/world/2022/mar/12/dismay-as-funding-for-uks-world-beating-covid-trackers-is-axed
  9. Murray CH, Mokdad AH. After the Mandates End. Preparing for the next COVID-19 variant.https://www.thinkglobalhealth.org/article/after-mandates-end
  10. Dowd JB. The UK’s covid-19 data collection has been “world beating”—let’s not throw it away. BMJ 2022; 376 :o496.

Testing NHS Staff for Covid-19

There was no mention from the Chancellor, Rishi Sunak, in his speech on Wednesday 23 March 2022 about the continued funding of Covid-19 testing for NHS staff in England. We need the government to clarify this urgently and confirm whether twice weekly testing of healthcare workers will continue or stop in April 2022.

Under current guidance, NHS staff are required to test for Covid-19 twice weekly and report their results before coming to work. If testing is to continue from April onwards, then the NHS will have to find this funding from its existing budgets, reducing funding for other areas of care.

There has been discussion about staff paying for their own testing. My view is that if testing is required by NHS employers, they will need to fund the tests. Staff cannot be asked to fund their own tests if this is a condition of their employment.

Ending regular Covid-19 testing of NHS will increase the risk of infection spreading to vulnerable patients. But there are also costs associated with testing and we need a robust assessment of the evidence on which to base future testing policy for NHS staff.

Protecting yourself from Covid-19

The recent increase in Covid-19 rates in the UK is concerning although, to some extent, an increase in rates was expected now that control measures have ended in England, with the other three UK countries also ending most control measures as well.

We are also seeing signs of increased NHS pressures with more presentations of people with suspected or confirmed Covid-19 in primary care and hospital admissions increasing. The number of NHS staff off work due to Covid-19 is also adding to NHS pressures.

A key message for the public is that vaccination is essential. Many people have not come forwards for a booster vaccine, particularly in London and other large cities. Three doses of vaccine are essential to reduce the risks of serious illness and death from Covid-19.

A second booster programme is also now starting for the most vulnerable people in our society: people aged 75 years and over this living in care home and people who are immunocompromised. The additional booster will provide these people with greater protection from serious illness and death.

I also advise people to continue to wear a mask (preferably a FFP2 mask) when in shops and on public transport. People should also continue to self-isolate if they test positive for Covid-19 to reduce the risks of infection to others.

Given that infection rates are increasing again, people who are clinically vulnerable through age or their medical history need to be cautious about entering places where there is a high-risk of infection (i.e. crowded, indoor venues with poor ventilation).

The government should also continue with PCR testing for people with symptoms of a possible Covid-19 infection and not scale back testing as it seems to be planning from April onwards. Unfortunately, there is no easy way out of the pandemic and testing along with good infection control measures remain essential.

Why should I other getting a Covid-19 vaccine booster?

I have much bigger healthcare concerns than getting COVID-19, and the NHS doesn’t help me with them. Why should I bother to help them by getting this vaccine?

This is a question that some people often ask. By getting the Covid-19 vaccine, you are protecting yourself as well as reducing pressures on the NHS. Over 10 billion Covid-19 vaccines have been giving globally; and they have proven to be very safe and effective. The number of Covid-19 cases in the UK remains very high. Vaccines are protecting us and without them, we would be seeing many more people who are seriously ill or dying from Covid-19.

By getting vaccinated against Covid-19, you are substantially reducing your risk of a serious illness that may lead to you requiring hospital treatment or even dying. Even if you don’t need hospital treatment, Covid-19 can still be an unpleasant illness that can make you unwell for a few weeks or leave you with long-term complications.

The risks from Covid-19 are particularly high in those who are over 50 years of age, obese or who have underlying medical problems such as diabetes or kidney disease. Vaccination reduces all these risks to you. Furthermore, if too many people remain unvaccinated, this will increase the likelihood of the government having to introduce measures to control the spread of Covid-19 and reduce pressures on the NHS. This could mean, for example, bringing in restrictions on people attending large, indoor gatherings – or closing pubs, night clubs and restaurants – like the measures we have seen at times over the last two years.

It could even lead to another lockdown if pressures on the NHS were very high. These measures have had a big impact on people’s social lives and mental health, as well as on the economy, and we don’t want to see them brought back.

Finally, many countries across the world are now requiring proof of vaccination for tourists and visitors. If you are not vaccinated, you will find it difficult to visit these countries, thereby limiting your leisure opportunities or the chance to meet friends and family living overseas. So by getting vaccinated, you are not only helping the NHS. You are also helping yourself.

UK scales back routine Covid-19 surveillance

On 24 February 2022, the UK government removed the legal requirement for people in England to self-isolate after a positive covid-19 test result, with the other UK nations also easing restrictions.1 In doing so, the UK is acting ahead of many of its international peers to embark on a “vaccines only” strategy, hoping that existing immunity in the population will allow a “return to normal.” This view is in sharp contrast to public opinion. In a recent poll by market research company YouGov, only 17% of respondents thought that ending mandatory self-isolation was appropriate.2

The removal of legal restrictions makes the people of England part of an experiment in which much remains uncertain.3 This is acknowledged by chief government advisers Chris Whitty and Patrick Vallance, who accompanied Boris Johnson’s announcement with a warning that rates of covid-19 infection and hospital admission remain high.4 Of equal concern, the government’s announcement also introduced plans to scale back two crucial pillars of the UK’s covid-19 surveillance: the Office for National Statistics’ (ONS) covid-19 infection survey and daily reporting of data on the UK Health Security Agency (UKHSA) covid-19 dashboard.15 When, and to what extent, these important resources will be scaled back remains unclear.

The ONS survey is a world leading example of random population sampling to estimate covid-19 prevalence over time.67 The UKHSA dashboard has been a vital resource for the public, clinicians, journalists, and researchers, allowing them to identify local trends as well as providing national data. The dashboard received up to 19 million hits a week in September 2021.8 Data to understand and promptly respond to covid-19 outbreaks are essential for public health and the NHS, as well as for the wider public.

We remain in the middle of a global pandemic caused by a novel pathogen and complicated by the repeated emergence of new variants. Policy decisions to manage new outbreaks rely on robust and timely data—the alpha, delta, and omicron variants all became dominant in the UK within weeks of the first reported cases.9 Although omicron is associated with a significantly lower risk of hospital admission and death than previous variants, the government’s Scientific Advisory Group for Emergencies (SAGE) acknowledges that this may be the exception rather than the rule, emphasising the need for ongoing vigilance to detect future variants.10

From 1 April 2022, when universal free covid tests are withdrawn leaving only limited testing in place, most SARS-Co-V infections in England will remain undetected and unreported. Our ability to track the emergence of new variants or trends in the incidence of infection and disease will become more reliant on robust, cross sectional surveys such as the ONS survey. Scaling back the survey, as proposed, risks missing emerging variants or concerning rises in prevalence that could herald the need for further restrictions; moreover, the survey cannot provide accurate and timely local data, as currently provided by the UKHSA dashboard. The detrimental effects of delayed action are now abundantly clear, and we must not fall behind at this critical moment when the UK’s pandemic is gradually coming under control.11

In announcing the latest relaxation of restrictions, the prime minister asked the public to take individual responsibility for their actions, yet informed decisions are reliant on the availability and accessibility of information. Throughout the pandemic people have relied on regional reporting of covid-19 cases on government dashboards and in news media, and they will continue to need such accessible information for the foreseeable future.

While most people have received two or more doses of a covid-19 vaccine, almost 10% of adults in England have not received a single dose and around 30% have not had a booster.12 Many others remain at high risk of disease despite vaccination because of underlying health conditions. The public health implications of immunity waning over time remain uncertain.1314 As we move into a period of largely optional (and paid for) testing and voluntary self-isolation, it is crucial that people have easy access information to guide their actions and help minimise covid-19 risks to themselves and their families.

The UK has been a world leader in the routine surveillance of covid-19 and the transparent reporting of covid-19 data. Scaling back vital data systems prematurely is a false economy and may need to be reversed to manage future waves of infection. The UK has the resources and infrastructure to continue existing surveillance, which has clearly identifiable benefits. We need to sustain our existing surveillance capabilities until we are certain that the pandemic is over in the UK, which won’t be until covid-19 is controlled globally.

Jonathan Clarke, Thomas Beaney, Azeem Majeed

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

DOI: https://doi.org/10.1136/bmj.o562

Factors associated with accessing long-term social care in older people

The rise in demand for healthcare by an ageing population together with budgetary constraints has put great pressure on the availability of adult social care (ASC). In response, healthcare organisations and researchers have developed practices of care and support, focusing on prolonging functional independence  This is done through exploring possible risk factors associated with unplanned outcomes, typically readmissions to hospital or through the use of predictive models to forecast outcomes.

Predictive models are widely used by health care providers in the UK and US due to their potential to inform early interventions. However, equivalent models for predicting new onset of long-term ASC, defined as need for help with tasks of daily living in the community or in care homes, are rare, particularly those using administrative data.

In this study published in Age and Ageing, we describe risk factors for long-term ASC in two inner London boroughs and develop a risk prediction model for long-term ASC. Pseudonymised person-level data from an integrated care dataset were analysed. We used multivariable logistic regression to model associations of demographic factors, and baseline aspects of health status and health service use, with accessing long-term ASC over 12 months.

The cohort comprised 13,394 residents, aged ≥75 years with no prior history of ASC at baseline. Of these, 1.7% became ASC clients over 12 months. Residents were more likely to access ASC if they were older or living in areas with high socioeconomic deprivation. Those with pre-existing mental health or neurological conditions, or more intense prior health service use during the baseline period, were also more likely to access ASC. A prognostic model derived from risk factors had limited predictive power.

Our findings reinforce evidence on known risk factors for residents aged 75 or over, yet even with linked routinely collected health and social care data, it was not possible to make accurate predictions of long-term ASC use for individuals. We propose that a paradigm shift towards more relational, personalised approaches, is needed.

DOI: https://doi.org/10.1093/ageing/afac038

Should GPs in England be employed by the NHS?

The intense micromanagement of general practices by NHS England since the start of the Covid-19 pandemic in early 2020 has shattered the illusion that NHS general practitioners are truly “independent”. For example, during the pandemic, NHS general practices have often received weekly updates from NHS England on how they should provide primary care services.[1] The opening hours and working arrangements of general practices are also highly regulated by NHS England. And general practitioners are not independent contractors in the same way that professionals working in other fields or indeed primary care physicians working overseas would recognise. General practitioners are not even able to offer private medical services to their patients in the same way as NHS Trusts or dentists are able to do. In effect, they have all the disadvantages of being self-employed contractors and none of the benefits of being NHS employees.

For more than a decade, primary care in England has suffered from under-investment, and a lack of key staff such as general practitioners and practice nurses. The NHS hospital sector in contrast – although it also has its problems – has seen its funding and medical staffing increase at a much quicker rate than in NHS primary care.[2] And yet despite this, more NHS work continues to be shifted to primary care without being followed by a commensurate increase in funding and staffing. Attempts by NHS England to prevent this – such as the introduction of the NHS Hospital Contract – have failed.[3] It’s very clear that NHS England is not going to invest adequately in the current independent contractor model of general practice, making being a GP Partner increasingly unattractive for younger general practitioners.[4] It’s time therefore to look seriously at the alternative – GPs becoming salaried employees of the NHS.

Of course, being employed by the NHS is not a panacea. Many NHS staff employed by NHS Trusts suffer from stress and over-work, just like those working in primary care. But they are not personally responsible for the ownership of their employing organisations, and their income does not depend on how well their organisation performs financially. Their working hours are also better regulated than those of self-employed GPs.

If GPs had employment contracts similar to those of NHS consultants, they could then have job plans with time allocated for activities such as quality improvement, NHS management, teaching, training, and research. Currently, these activities are often done on top of their regular working hours. Working in organisations that employed large numbers of GPs would also create opportunities for a better career structure. For example, it may be possible to create posts for GPs who specialise in areas such as the care of the elderly or in child health; and for GPs who take on clinical leadership, quality improvement and NHS management roles in addition to a clinical role.[5]

Finally, GPs becoming NHS employees would make NHS England directly responsible for the delivery of primary care services, in the same way they already are for specialist services. It would be the responsibility of NHS England – not GPs – to ensure that patients had timely access to a comprehensive range of high-quality primary care services and the infrastructure needed to deliver this care.

An increasing proportion of NHS GPs are already salaried. The future for GPs therefore looks to be heading in this direction. The question for GPs is do they want to be employed by the NHS with similar terms of employment to consultants; or do they want to be employed by private companies and “mega-partnerships” with the inevitable variability in terms of employment that they will offer?

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

DOI: https://doi.org/10.1136/bmj.o406

References

1. Majeed A, Maile EJ, Bindman AB. The primary care response to COVID-19 in England’s National Health Service. Journal of the Royal Society of Medicine. 2020;113(6):208-210.

2. Anderson M, O’Neill C, Clark JM, Street A, Woods M, Johnston-Webber C, et al. Securing a sustainable and fit-for-purpose UK health and care workforce. The Lancet. 2021 May 22;397(10288):1992-2011.

3. Price A, Majeed A. Improving how secondary care and general practice in England work together: requirements in the NHS Standard Contract. Journal of the Royal Society of Medicine. 2018;111(2):42-46.

4. Rimmer A. GPs move towards industrial action after rejecting “rescue plan” for general practice BMJ 2021; 375:n2594

5. Majeed A, Buckman L. Should all GPs become NHS employees? BMJ 2016; 355:i5064