Month: August 2017

Warning signs might have been missed in one in six heart attack deaths in England

Heart attack symptoms might have been missed in many patients, according to a study on all heart attack hospital admissions and deaths in England from Imperial College London. More research is urgently needed to establish whether it is possible to predict the risk of fatal heart attacks in patients for whom this condition was not recorded as the main reason for hospital admission. The study was published in The Lancet Public Health.

Heart disease is one of the leading killers in the UK. According to the British Heart Foundation, heart attacks lead to one hospital visit every three minutes. They are caused by a decrease in blood flow to the heart, usually as a result of coronary heart disease. Symptoms may include sudden chest pain or a ‘crushing’ sensation that might spread down either arm. Patients might also experience nausea or shortness of breath. However, some heart attacks have more subtle symptoms and may therefore be missed or overlooked.

In this study, we examined records of all 446,744 NHS hospital stays in England between 2006 and 2010 that recorded heart attacks, as well as the hospitalisation history of all 135,950 heart attack deaths. The records included whether or not patients who died of a heart attack had been admitted to hospital in the past four weeks and if so, whether signs of heart attack were recorded as the main cause of admission (primary diagnosis), additional to the main reason (secondary diagnosis), or not recorded at all.

Of the 135,950 patients who died from heart attack, around half died without a hospital admission in the prior four weeks, and around half died within four weeks of having been in hospital. 21,677 (16 per cent, or one in six) of the patients who died from heart attack had been hospitalised during the four weeks prior, but heart attack symptoms were not mentioned on their hospital records.

There were certain symptoms, such as fainting, shortness of breath and chest pain, that were apparent up to a month before death in some of these patients, but doctors may not have been alert to the possibility that these signalled an upcoming fatal heart attack, possibly because there was no obvious damage to the heart at the time.

These results suggest that possible signs of upcoming fatal heart attack may have been missed. The authors’ next step is to look into why this pattern emerged, and to try to prevent more heart attack deaths. We also found that of all patients admitted with a heart attack, those whose heart attack was recorded as secondary to the main condition were two to three times more likely to die than patients whose records stated heart attack as the main condition.

The study received extensive media coverage including by the BBC, The Independent and the Daily Telegraph.

DOI: http://dx.doi.org/10.1016/S2468-2667(17)30032-4

Releasing student potential: Widening access to opportunities in community healthcare

The WATCCH Team at the Department of Primary Care and Public Health

This summer, the Department of Primary Care and Public Health kicked off an exciting new programme: Widening Access to Careers in Community Healthcare (WATCCH). We hosted twenty 16-17 year olds who are aspiring to be the first in their families to go to university – at the Charing Cross campus for the inaugural WATCCH project. Our aim was to change perceptions of wider healthcare careers and provide vital work experience for their University applications. Competition was high and the team was very impressed by the number of high calibre students that applied for a place.

Year 12 Pupils from 19 London secondary schools attended an induction day in late July. During the workshop, an experienced multi-professional panel consisting of five professionals including an Imperial final year medical student, shared their career journeys with the pupils from their A level to postgraduate degrees. This was followed by pupils creating individual mind maps, which they thoroughly enjoyed, of where they are now and where they would like to be in the future. This was followed by a fun exercise in the clinical skills lab at Charing Cross where they could experience clinical skills such as phlebotomy, measuring blood pressure, and inserting nasogastric tubes into mannequins.

The pupils, in pairs, will now attend a 3-day work experience attachment at a General Practice over the summer, where they shadow various health care professionals ranging from pharmacists, to phlebotomists, nurses, physiotherapists and GPs.

Our budding health professionals reported that they had their eyes opened to new and different careers in healthcare they were not previously aware of. One pupil commented that they had learnt “how the different healthcare professionals work together to provide the best quality care”. Another said they had “learnt more about the opportunities available and how to find them”. Pupils also felt they got an insight into how to provide the best quality care, with admiration for the way in which different healthcare professionals worked as a team. It was even said that you “will never get bored” in healthcare!

In early September, we will run a final workshop day to review their reflections of what they have learnt and gained from their work experience. They have been advised to do a placement project to showcase something they have learnt from their attachment which they will share at the final workshop. The mind maps will be revisited to review if their thoughts have changed following the placement. We also hope to discuss how to incorporate their work experience into their personal statements for UCAS applications.

The WATCCH project is needed now more than ever. Figures from the Office for Fair Access (OFFA) show that in 2016 entry rates to “higher tariff” universities for 18-year-olds from the most disadvantaged neighbourhoods stood at just 3.6%. This is exaggerated within the health sector, where there is also a shortage of work experience, despite it being essential for applications. The shortage is particularly acute for those who have no family or social connections to healthcare professionals, despite good GCSE grades.

The NHS workforce is certainly facing a recruitment crisis and our aim is to help channel and support able and enthusiastic applicants towards a brighter future in healthcare. A well-functioning multi-professional team in the community will aid primary care in delivering better patient care

Students at the Clinical Skills Lab at Charing Cross Hospital

The GP teaching team at the Department of Primary Care and Public Health were instrumental in facilitating the induction day. If you would like further information about the WATCCH programme contact Dr Farah Jamil, lead GP for the WATCCH programme, at f.jamil@imperial.ac.uk.

Is there still a role for smaller hospitals in the NHS?

A paper published in the British Journal of Hospital Medicine asks the questions “Is there a role for smaller hospitals in the future NHS?”

The NHS is challenged by rising demand as a consequence of a population with more complex conditions and the rising costs of paying for that care. Inefficiencies resulting from fragmented primary, secondary and social care services highlight the need for greater coordination and continuity to improve patient outcomes at lower cost. Financial constraints can drive health system review, providing impetus to modify health service delivery within the NHS to maximize value and better align with the needs of our population.

The Naylor (2017) review calls for urgent rationalization of the NHS estate to meet the mandate of the Five Year Forward View. Smaller acute hospitals could be seen as a potential starting point for reconfiguring health services in England. However, local change is not always welcome and the perceived loss of services is often met with staunch political and public opposition.

The NHS Chief Executive Officer, Simon Stevens, has expressed his support for smaller hospitals. In the Five Year Forward View, smaller hospitals have an opportunity to once again be at the centre of defining patient pathways. This will require some change in provision of services. Gaining local public and clinician support will be crucial and small hospital leaders must be visionary. Support programmes such as the New Cavendish Group and New Care Models programme will be increasingly important in helping to ensure that smaller hospitals remain part of the fabric of the English NHS.

DOI: https://doi.org/10.12968/hmed.2017.78.8.424

The burden of disease in the World Health Organization’s Eastern Mediterranean Region

I contributed to a series of papers on health in the World Health Organization’s Eastern Mediterranean Region. Key steps that need to be taken to improve the health and well-being of people in the region must include ending the wars and conflicts in the region, as well as improving education and employment opportunities, particularly among women. Health systems must be strengthened as well, for example, through building up primary care and using health programmes to target the causes of ill-health, such as high-calorie diets, smoking, physical inactivity and obesity. In addition, health workers and governments should aim to improve maternal and child health and ensure that immunisation rates are high, as well as addressing environmental factors such as air pollution. You can read more on the Imperial College Website.

The papers were published in the International Journal of Public Health. Papers in the series include:

Diabetes mellitus and chronic kidney disease in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 study

doi:10.1007/s00038-017-1014-1

Burden of obesity in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 study

doi:10.1007/s00038-017-1002-5

Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 Study

Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare?

Policy-makers in many countries are increasingly considering charging people different fees for using primary and secondary care services (differential user charges). The aim of such ‘differential fees’ is to encourage use of primary health care in health systems with limited gate keeping.

We carried out a systematic review to evaluate the impact of introducing differential user charges on service utilisation. We reviewed studies published from January 1990 until June 2015. We extracted data from the studies meeting defined eligibility criteria and assessed study quality using an established checklist. We synthesized evidence narratively.

Eight studies from six countries met our eligibility criteria. The overall study quality was low, with diversity in populations, interventions, settings, and methods. Five studies examined the introduction of or increase in user charges for secondary care, with four showing decreased secondary care utilisation, and three showing increased primary care utilisation. One study identified an increase in primary care utilisation after primary care user charges were reduced. The introduction of a non-referral charge in secondary care was associated with lower primary care utilisation in one study. One study compared user charges across insurance plans, associating higher charges in secondary care with higher utilisation in both primary and secondary care.

Our conclusion was that the impact of introducing differential user-charges on use of primary care remains uncertain. Further research is required to understand their impact, including implications for health system costs and on utilisation among low-income patients.

The full article can be read in the journal Health Policy and Planning.

How well does the NHS Health Check Programme reach under-served groups?

A study from my department published in the journal BMC Health Services Research assessed how effective the NHS Health Check Programme was in reaching under-served groups.

Cardiovascular disease (CVD) is the leading cause of premature mortality and a major contributor of health inequalities in England. Compared to more affluent and white counterparts, deprived people and ethnic minorities tend to die younger due to preventable CVD associated with lifestyle. In addition, deprived, ethnic minorities and younger people are less likely to be served by CVD prevention services. This study assessed the effectiveness of community-based outreach providers in delivering England’s National Health Services (NHS) Health Check programme, a CVD preventive programme to under-served groups.

Between January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appointments. Community outreach providers operated on evenings and weekends as well as during regular business hours in venues accessible to the general public. After exclusion criteria, we analysed and compared socio-demographic data of 43,177 Health Check attendees with the general population across 38 local authorities (LAs).

Using Index of Multiple Deprivation, the mean deprivation score of the population reached by community outreach providers was 6.01 higher (p < 0.05) than the general population. Screened populations in 29 of 38 LAs were significantly more deprived (p < 0.05). No statistically significant difference among ethnic minority groups was observed between LAs. Nonetheless some LAs – namely Leicester, Thurrock, Sutton, South Tyneside, Portsmouth and Gateshead were very successful in recruiting ethnic minority groups. The mean proportion of men screened was 11.39% lower (p < 0.001) and mean proportion of 40–49 and 50–59 year olds was 9.98% and 3.58% higher (p < 0.0001 and p < 0.01 respectively) than the general population across 38 LAs.

We concluded that community-based outreach providers effectively reach under-served groups by delivering preventive CVD services to younger, more deprived populations, and a representative proportion of ethnic minority groups. If the programme is successful in motivating the under-served groups to improve lifestyle, it may reduce health inequalities.

Changes in the Roles of Health Care Professionals in Primary Care in England’s National Health Service

In an article published in the Journal of Ambulatory Care Management, Dr Sonia Kumar and I discuss the change in the roles of doctors and other health professionals in England’s NHS. Primary care in England has seen a slow but steady expansion in the roles and numbers of non-medical health care professionals over the last 50 years. In the next 5 to 10 years, the use of non-medical professionals will expand rapidly in primary care, with currently unknown consequences for patient outcomes and England’s NHS. Doctors in England will find their traditional professional autonomy slowly decreasing as they increasingly work in multi-professional teams; and the education and professional development of our medical students and doctors need to change to reflect these new ways of working.

A further challenge (and opportunity) for doctors arises from the rapid advances we are seeing in information technology. Through the Internet and Web sites such as NHS Choices, patients in the United Kingdom now have easy access to medical information. We are also now seeing developments in artificial intelligence (AI) leading to alternative routes for accessing medical and health promotion advice. For example, the NHS has now begun trialing AI-based “chatbots” that will be used to offer health advice to patients when they contact the NHS telephone advice line (NHS 111) for medical advice. If these trials are successful, we may see a rapid development in the capabilities and use of AI-driven health chatbots in England and elsewhere.

Health Effects of Overweight and Obesity in 195 Countries

Globally, more than 2 billion children and adults suffer from health problems related to being overweight or obese, and an increasing percentage of people die from these health conditions, according to a new study published in the New England Journal of Medicine, to which I contributed.

They are dying even though they are not technically considered obese. Of the 4.0 million deaths attributed to excess body weight in 2015, nearly 40% occurred among  people whose body mass index (BMI) fell below the threshold considered “obese.”

The findings represent “a growing and disturbing global public health crisis,” according to the authors of the paper published today in The New England Journal of Medicine.  In the UK, nearly a quarter of the adult population – 24.2% or 12 million people – is considered obese. Additionally, 1 million British children are obese, comprising 7.5% of all children in the UK.

Among the 20 most populous countries, the highest level of obesity among children and young adults was in the United States at nearly 13%; Egypt topped the list for adult obesity at about 35%. Lowest rates were in Bangladesh and Vietnam, respectively, at 1%. China with 15.3 million and India with 14.4 million had the highest numbers of obese children; the United States with 79.4 million and China with 57.3 million had the highest numbers of obese adults in 2015.

The study was reported by many media outlets including the Guardian and CBS News.

NHS England’s plan to reduce wasteful and ineffective drug prescriptions

I published an article in the British Medical Journal in August 2017 on NHS England’s plan to reduce wasteful and ineffective drug prescriptions. In the article, I explain why national rules on prescribing are a better approach than the variable local policies being implemented by clinical commissioning groups (CCGs, the NHS organisations responsible for funding local health services).

The National Health Service (NHS) in England must produce around £22 billion of efficiency savings by 2020. A key component of the NHS budget in England is primary care prescribing costs, currently around £9.2 billion annually. Inevitably, the NHS has begun to look at the drugs prescribed by general practitioners to identify areas in which savings could be made; ideally without compromising patient care or worsening health inequalities. This process was initially led by CCGs, focusing on drugs that are either of limited clinical value or which patients can buy from retailers without a prescription (referred to in England as ‘over the counter’ preparations).[1]

However, this local-based approach is flawed.[2] Firstly, CCGs have no legal power to limit the prescribing of drugs by general practitioners. As CCG policies on restricting prescriptions are not backed by statutory guidance, this will inevitably lead to variation between general practitioners in the use of the drugs that CCGs are proposing to restrict, thereby leading to ‘postcode prescribing’. It also raises legal issues in that if there is a complaint about a refusal to issue a prescription, it will be the general practitioner who will have to defend any complaint made by the patient and not the CCG. Each CCG carrying its own evidence review, public and professional consultation, and developing its own implementation policy also results in duplication of effort and is a poor use of NHS resources.[3]

NHS England has now launched its own consultation process to identify areas where ‘wasteful or ineffective’ prescribing can be reduced.[4] However, although a national process is better than local processes, NHS England has not stopped CCGs from continuing to roll-out their own restrictions on prescribing, even though some of these will inevitably conflict with the guidance produced by NHS England when it completes its consultation process.

In its consultation document, NHS England proposes restrictions on prescribing for a range of drugs. Stopping prescribing in some areas – such as homeopathy and herbal remedies – will not be controversial but will also not save much money. Some other drugs that NHS England is proposing to restrict, such as liothyronine, have limited evidence for their benefits but some patients do find them useful, and there will be resistance from patients and from some clinicians about the proposed restrictions on their use.

The two most controversial areas will be around NHS prescriptions for gluten-free foods, for which there was a separate consultation;[5] and NHS prescriptions for drugs available over the counter. In the case of gluten-free foods, these are essential for people with coeliac disease and although gluten-free foods are now much more widely available from retailers than in the past, many patients with coeliac disease continue to receive NHS prescriptions and will resist strongly any restrictions on the availability of gluten-free foods through the NHS[6]. For drugs available over the counter, for example treatments for headlice or hay-fever, many patients will be able to pay for them out-of-pocket. Some poorer patients though will struggle with the costs of buying such drugs.

NHS England is to be congratulated for launching its public consultation and not just leaving decisions about eligibility for NHS treatment to individual CCGs.[7] However, it needs to ensure that its recommendations are accepted by CCGs and that the restrictions on prescribing that some CCGs are trying to impose fall into line with national recommendations. NHS England also needs to make the necessary changes to the National General Practice Contract and to the NHS Drugs Tariff to ensure that any prescribing restrictions it imposes have a firm legal basis. If this is not done, it places general practitioners in the invidious position of being at clinical and legal risk if they adopt NHS England’s prescribing guidance when this is finally published, at a time when they are already under considerable workload pressure.[8,9]

Restrictions on prescribing and the reduced availability of drug treatments on the NHS will have adverse consequences. For example, there is a risk of unintended effects such as codeine-based analgesics being used in place of simpler analgesics like paracetamol or Ibuprofen if the use of the latter is restricted. We also need to ensure that prescribing restrictions do not affect patients with very serious conditions. For example, if restrictions are imposed on NHS prescriptions of laxatives because these are available to buy from retailers, this will impact on patients with cancer, in whom constipation is a common and distressing symptom.

There will also be a risk that poorer patients, who are less able to pay for their own medication, will suffer disproportionately from these restrictions, thereby exacerbating health and social inequalities.[10] Ultimately, however, politicians  and the public must understand that the financial savings the NHS in England needs to make are so large, they cannot be made without substantial cuts to the provision of publicly-funded health services; and without patients making a greater financial contribution to the costs of their health care.[11,12]

doi: https://doi.org/10.1136/bmj.j3679

References
1. North West London Collaboration of Clinical Commissioning Groups. Choosing wisely – changing the way we prescribe. https://www.healthiernorthwestlondon.nhs.uk/news/2017/06/12/choosing-wisely-changing-way-we-prescribe
2. Iacobucci G. Doctors call for national rules on OTC prescribing. BMJ 2017;356:j1442
3. Phizackerley D. National approach to OTC prescribing is needed. BMJ 2017;357:j1849.
4. NHS England. Items which should not be routinely prescribed in primary care: a consultation on guidance for CCGs. https://www.engage.england.nhs.uk/consultation/items-routinely-prescribed/
5. Department of Health. Availability of gluten-free foods on NHS prescription. https://www.gov.uk/government/consultations/availability-of-gluten-free-foods-on-nhs-prescription
6. Kurien M, Sleet S, Sanders DS, Cave J. Should gluten-free foods be available on prescription? BMJ 2017;356:i6810.
7. Iacobucci G. NHS to stop funding homeopathy and some drugs in targeted savings drive BMJ 2017;358:j3560.
8. British Medical Association. BMA responds to NHS England action plan on wasteful drug use. https://www.bma.org.uk/news/media-centre/press-releases/2017/july/bma-responds-to-nhs-england-action-plan-on-wasteful-drug-use
9. Majeed A. Shortage of general practitioners in the NHS. BMJ 2017;358:j3191.
10. Gleed G. Commentary: We’re under financial strain without prescriptions for gluten-free food. BMJ 2017;356:j119.
11. Toynbee P. Feet first, our NHS is limping towards privatization. The Guardian, 16 August 2016. https://www.theguardian.com/commentisfree/2016/aug/16/feet-nhs-limping-towards-privatisation-podiatry-diabetic-amputations
12. Iacobucci G. GPs urge BMA to explore copayments for some services. BMJ 2017;357:j2503.

Interview with the British Medical Journal

The BMJ published an interview with me earlier this year for their ‘Observations‘ section.

What was your earliest ambition?
As a boy I was keen to be a pilot. My poor eyesight put an end to that ambition.

Who has been your biggest inspiration?
Two of my former consultants, James Stuart and Keith Cartwright, who mentored me early in my career, helped me write my first scientific papers, and started me on my academic career path.

What was the worst mistake in your career?
Early in my career I admitted a man who had undergone some changes in behaviour after a minor head injury. I did not consider ordering a CT scan immediately, but fortunately my senior registrar did, and a diagnosis of a subdural haematoma was made. The patient underwent surgery that evening and had a good outcome.

What was your best career move?
Moving to London in the 1990s to take up my first academic post. Although I was unsure about moving to such a large city, having always lived in much smaller towns, working in London opened up many professional and academic opportunities to me.

Who has been the best and the worst health secretary in your lifetime?
William Waldegrave and Frank Dobson both tried their best for the NHS. Those who followed them, from Alan Milburn onwards, have been far less successful.

Who is the person you would most like to thank, and why?My wife, for supporting me in my personal and professional life.

To whom would you most like to apologise?
The patients in my medical practice. As an academic GP I see them only one day a week. Because of this, many of my patients think I work only part time and have a very easy life. I can assure them that I do work full time.

If you were given £1m what would you spend it on?
Education is the key to development, so I would use the money to support university scholarships in a low income country.

Where are or were you happiest?
I am happiest when on holiday with my family in Pembrokeshire, which I visit regularly.

What single unheralded change has made the most difference in your field in your lifetime?
The development of the internet and the rapid and easy access to medical information it has made possible for patients, clinicians, and academics.

What book should every doctor read?
The Citadel by A J Cronin. Though it was published in 1937, its core messages are still relevant to doctors. For a non-medical book I would recommend The Conquest of New Spain by Bernal Diaz del Castillo, a fascinating contemporary account of the overthrow of the Aztec empire by the Spanish and their local allies.

What poem, song, or passage of prose would you like mourners at your funeral to hear?“Do not go gentle into that good night” by Dylan Thomas.

What is your guiltiest pleasure?
Chocolate. But don’t tell my patients.

What television programmes do you like?
When I have time I enjoy watching scientific, historical, and current affairs programmes.

What is your most treasured possession?
My family and friends. All the material objects I own can be replaced.

What, if anything, are you doing to reduce your carbon footprint?
I am taking far fewer overseas trips and hence flying a lot less now than in the past. I have also switched my house to LED lights.

What personal ambition do you still have?
General practice and the rest of the NHS are going through a very difficult period. I would like to see my general practice continue to provide high quality, accessible care to the people of Clapham.

Summarise your personality in three words
Honest, conscientious, logical.

What is your pet hate?
Politicians who do not base policy on evidence. Many of the problems we now face in the NHS are because of this.

What would be on the menu for your last supper?
A salmon starter, followed by roast chicken with vegetables, and finished off with bread and butter pudding.

Do you have any regrets about becoming a doctor and an academic?
No. I am very grateful that I have had the opportunity to be an academic doctor. Being an academic and a clinician opened a tremendous career path for me.

If you weren’t in your present position what would you be doing instead?
If I weren’t a doctor I would have probably pursued a career in a field such as information technology or accountancy.