Blog posts

Should all GPs become NHS employees?

In a debate article in the BMJ, Laurence Buckman and I discuss the arguments for against GPs in England becoming NHS employees. Primary care in England’s NHS is in crisis. Recruitment of GPs is difficult throughout England, with many practices reporting vacant posts; many GPs are considering retiring early, and others want to cut down on their clinical work. The problems faced by GPs are partly due to the contracts that general practices have to provide NHS services and the way secondary care is organised. These contracts encourage the NHS to transfer work to primary care with the expectation that GPs will pick up this work at little or no extra cost. Most GPs would have no problem with taking on such work if they were given time to deal with it during their current working week. If GPs had employment contracts similar to NHS consultants they could have job plans, with time allocated for clinical work and for activities such as administration, teaching, training, and research.

Read the full article on the BMJ website.

Video consultations can improve both access to GPs and patient experience

The NHS should make better use of video consultations because they can boost patient access and save time and money for both patients and doctors, concludes preliminary research presented at this year’s International Forum on Quality & Safety in Healthcare in Kuala Lumpur (24-26 August).

Current challenges in the UK medical workforce are well known, making accessing a GP in a timely manner difficult, say the researchers (including myself) from Chelsea and Westminster Hospital NHS Foundation Trust and the Department of Primary Care and Public Health at Imperial College London.

The estimated total number of consultations in England rose from 224.5 million in 1995-6 to 303.9 million in 2008-9, with an average wait for a GP appointment of two weeks in some parts of the country. In light of these difficulties, weset up a trial video consultation clinic in two busy London general practices, with lists of nearly 10,000 patients.

Twice weekly video clinics were set up for 23 months to gauge the impact on patient access and to assess whether these could work alongside or possibly replace conventional face-to-face appointments. Initial doctor concerns included security and governance issues, while the absence of a physical examination worried some patients.

In all, 192 video consultations took place over the trial period. Only three patients didn’t attend their appointment compared with 576 no shows for face-to-face appointments over the same period.

Based on average appointment costs, this is a potential cost saving of £61,884 for just these two practices. We suggested that remote accessibility of video consultations and the reduction in travel time and delays might explain the findings.

The trial results prompted the practices to regularly offer video consultations. Traditional face-to-face appointments were available for patients with more long-term or complex health needs, to ensure that those needing more time with GPs accessed services appropriately.

“Clearly video consultations have a place in a health care system to improve access to primary care,” says the lead author Dr Mateen Jiwani. They offer an additional visual sensory component to consulting compared to telephone appointments, enabling clinicians to make safer decisions and carry out more effective triage, he added.

“With an increase in technology usage and remote socialising being the everyday norm, communicating with your doctor remotely will become a mainstay of future medical practice and self-care,” Dr Jiwani concludes. Evidently, the demand is there, he suggests.

Source: Jiwani M, Majeed A, Tahir A. The doctor will see you now….online. Presentation at the International Forum on Quality & Safety in Healthcare, 2017.

Read the news reports from Onmedica and the BMJ.

Government’s anti-immigration stance following the vote for Brexit alarms UK scientists

I was interviewed by the scientific journal Nature on the impact of the vote for Brexit and recent statements from government ministers on the recruitment and retention of scientific staff from outside the UK. I made the point that the success of our universities and their world-leading status depends in part on their ability to recruit leading scientists from across the globe. If this recruitment is threatened, then our universities – which make an essential contribution to our society – will be weakened.

Can GPs refuse to treat dental abscesses?

I was asked by the professional magazine medical Pulse to discuss the question of whether GPs can refuse to treat dental abscesses.

A study published in 2016 reported that around 600,000 consultations annually with GPs are for dental problems. Reasons why people present to GPs with dental problems include the poor provision of NHS dental services in many parts of England and the £19.70 charge that some patients must pay for a dental consultation.

If you decide that your patient may have a dental abscess, assuming there are no red flags (such as signs of spreading infection or sepsis) that would warrant an urgent referral for emergency hospital assessment, then the patient should be informed that they need to see a dentist. You should explain to the patient that a dentist is trained to treat dental abscesses but you are not. The dentist has the expertise and equipment needed to assess the patient, carry out suitable investigations (such as dental radiographs), and drain the abscess if this is required.

The dentist can also treat any underlying problems, through procedures such as root canal treatment or a tooth extraction, to minimise the risk of recurrence of the abscess. You should also explain to the patient that issuing an antibiotic is an inadvisable course of action for GPs for someone with a suspected dental abscess as this won’t address the underlying problem; may mask symptoms and result in a worse long-term outcome for the patient; and will encourage the development of antimicrobial resistance. If the patient does not have a regular dentist, inform them they can call NHS 111 or use the NHS Choices website to find the location of local services for emergency dental treatment.

It is NHS England and NHS commissioners, and not GPs, who are responsible for ensuring the population has access to adequate NHS dental services. This includes access to services for emergency dental treatment.

The published article can be read in Pulse, along with the views of two other doctors.

Global deaths, prevalence and disability for chronic obstructive pulmonary disease and asthma

A recent paper from the Global Burden of Disease (GBD) Chronic Respiratory Disease Collaborators examined the burden of ill-health caused by chronic obstructive pulmonary disease (COPD) and asthma. The paper was published in the journal The Lancet Respiratory Medicine.

COPD and asthma are common diseases with a heterogeneous distribution worldwide. In the paper, we presented findings for COPD and asthma from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2015 study. The GBD study provides annual updates on estimates of deaths, prevalence, and disability for over 300 diseases and injuries, for 188 countries from 1990 to the most recent year.

We found that in 2015, 3.2 million people died from COPD worldwide, an increase of 11·6% compared with 1990. There was a decrease in age-standardised death rate of 41·9% but this was counteracted by population growth and ageing of the global population. From 1990 to 2015, the prevalence of COPD increased by 44%, whereas age-standardised prevalence decreased by 14·7%.

In 2015, 0·4 million people died from asthma globally, a decrease of 26·7% from 1990. The age-standardised death rate decreased by 58·8% (39·0 to 69·0). The prevalence of asthma increased by 12·6% whereas the age-standardised prevalence decreased by 17·7%.

Smoking and ambient particulate matter were the main risk factors for COPD followed by household air pollution, occupational particulates, ozone, and second-hand smoke. Together, these risks explained 73% of disability due to COPD. Smoking and occupational asthma precipitants were the only risks quantified for asthma in GBD, accounting for 16.5% (disability due to asthma.

In conclusion, asthma was the commonest chronic respiratory disease worldwide in 2015, with twice the number of cases of COPD. Deaths from COPD were eight times more common than deaths from asthma.

We also concluded that although there are laudable international collaborative efforts to make surveys of asthma and COPD more comparable, no consensus exists on case definitions and how to measure disease severity for population health measurements like GBD. Comparisons between countries and over time are important, as much of the chronic respiratory burden is either preventable or treatable with affordable interventions.

https://doi.org/10.1016/S2213-2600(17)30293-X

Impact of the organisation and performance of health systems on the control of the Ebola outbreak in West Africa

An Ebola outbreak started in December 2013 in Guinea and spread to Liberia and Sierra Leone in 2014. The health systems in place in the three countries lacked the infrastructure and the preparation to respond to the outbreak quickly and the World Health Organisation (WHO) declared a public health emergency of international concern on August 8 2014. We conducted a study to determine the effects of health systems’ organisation and performance on the West African Ebola outbreak in Guinea, Liberia and Sierra Leone and lessons learned. The WHO health system building blocks were used to evaluate the performance of the health systems in these countries.

A systematic review of articles published from inception until July 2015 was conducted following the PRISMA guidelines. The review was supplemented with expert interviews where participants were identified from reference lists and using the snowball method.  Ensuring an adequate and efficient health workforce is of the utmost importance to ensure a strong health system and a quick response to new outbreaks. Adequate service delivery results from a collective success of the other blocks. Health financing and its management is crucial to ensure availability of medical products, fund payments to staff and purchase necessary equipment. However, leadership and governance needs to be rigorously explored on their main defects to control the outbreak.

The findings from this study were published in the journal Globalization and Health.

Addressing polypharmacy in older people

A major challenge in healthcare, particularly for older people, is that patients are ending up on many medicines, termed ‘polypharmacy’. Polypharmacy can be either ‘appropriate’ or ‘problematic.’ With the latter, prescribing professions are traditionally better at starting medicines than stopping them (for a variety of reasons), which means that patients are too often left with problematic polypharmacy that can lead to side effects, interactions, and an inability to manage to take them all.

The NIHR Collaboration for Leadership in Applied Health Research and Care for Northwest London (CLAHRC NWL) have an active Medicines Optimisation work stream. A lot of work has been done around the need for medication review and stopping unnecessary medicines when problematic polypharmacy occurs. The term ‘deprescribing’ has emerged strongly in the literature and CLAHRC NWL have put together what we think is the first journal issue devoted to the topic of deprescribing.

The themed issue is particularly noteworthy due to the international contributorship, including key thinkers on this topic from Australia, Ireland, Israel, and UK. Barry Jubraj, Honorary Pharmacist for Medicines Optimisation at CLAHRC NWL, co-edited this themed issue and the CLAHRC NWL team contributed to several papers, including outlining a strategy for educating students and junior clinicians about the need to undertake medication reviews. This is a novel piece of work covering an issue close to the working practice of healthcare professionals in Imperial and beyond; the web version is currently available and the print version is forthcoming.

Improving discharge planning in NHS hospitals

Factors that need to be considered in discharge planning that have been identified in previous projects include:

  1. Ensuring that discharge arrangements are discussed with patients, family members and carers; and that they are given a copy of the discharge summary.
  2. Adequate coordination between the hospital, community health services, general practices, and the providers of social care services.
  3. There is a follow-up after discharge of patients at high risk of complications or readmission – either in person or by telephone – to ensure that the discharge arrangements are working well.
  4. Medicines reconciliation is carried out. This is the process of verifying patient medication lists at a point-of-care transition, such as hospital discharge, to identify which medications have been added, discontinued, or changed from pre-admission medication lists.
  5. Ensuring that any outstanding test results at discharge are obtained and passed on to primary care teams; and ensuring there are clear arrangements for carrying out and acting on any proposed post-discharge tests. In general, dealing with tests results is the responsibility of the clinical team that carried out the test.
  6. Give patients clear instructions about any post-discharge tests that are needed and how these will be carried out.
  7. Ensure that hospitals comply with the National NHS Standard Contract – for example, issuing Fit Notes for the expected duration of sick leave and supplying patients with an adequate amount of medication.

A useful summary of previous work on discharge planning (mainly based on US studies) can be viewed in UpToDate.

Does use of point-of-care testing improve the cost-effectiveness of the NHS Health Check programme?

A paper published in the journal BMJ Open examines if the use of point of care testing is less costly than laboratory testing to the National Health Service (NHS) in delivering the NHS Health Check programme in primary. To address this question, we carried out an observational study, supplemented by a mathematical model with a micro-costing approach.

We collected data on cost, volume and type of pathology services performed at seven general practices using point of care testing and a pathology services laboratory. We collected data on response to the NHS Health Check invitation letter and DNA rates from two general practices.

We found that the costs of using point of care testing to deliver a routine NHS Health Check is lower than the laboratory-led pathway; with savings of £29 per 100 invited patients up the point of cardiovascular disease risk score presentation. Use of point of care testing can deliver NHS Health Check in one sitting, whereas the laboratory pathway offers patients several opportunities to miss an appointment.

We concluded that the costs of using point of care testing to deliver an NHS Health Check in the primary care setting is lower than the laboratory-led pathway. Using point of care testing minimises non-attendance rates associated with laboratory testing and enables completion of NHS Health Check in one appointment.

DOI: http://dx.doi.org/10.1136/bmjopen-2016-015494

Improving the safety of care of people with dementia in the community

Dementia care is predominantly provided by carers in home settings. We aimed to identify the priorities for homecare safety of people with dementia according to dementia health and social care professionals using a novel priority-setting method. The study was published in BMC Geriatrics.

The project steering group determined the scope, the context and the criteria for prioritization. We then invited 185 North-West London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to homecare safety of people with dementia. 76 clinicians submitted their suggestions which were thematically synthesized into a composite list of 27 distinct problems and 30 solutions. A group of 49 clinicians arbitrarily selected from the initial cohort ranked the composite list of suggestions using predetermined criteria.

Inadequate education of carers of people with dementia (both family and professional) is seen as a key problem that needs addressing in addition to challenges of self-neglect, social isolation, medication non-adherence. Seven out of top 10 problems related to patients and/or carers signalling clearly where help and support are needed. The top ranked solutions focused on involvement and education of family carers, their supervision and continuing support. Several suggestions highlighted a need for improvement of recruitment, oversight and working conditions of professional carers and for different home safety-proofing strategies.

Clinicians identified a range of suggestions for improving homecare safety of people with dementia. Better equipping carers was seen as fundamental for ensuring homecare safety. Many of the identified suggestions are highly challenging and not easily changeable, yet there are also many that are feasible, affordable and could contribute to substantial improvements to dementia homecare safety.

DOI: 10.1186/s12877-017-0415-6