Author: Azeem Majeed

I am Professor of Primary Care and Public Health, and Head of the Department of Primary Care & Public Health at Imperial College London. I am also involved in postgraduate education and training in both general practice and public health, and I am the Course Director of the Imperial College Master of Public Health (MPH) programme.

Career opportunities for GPs in North and West London

On Wednesday 22 November 2017, I spoke at an event organised by the North and West London Faculty of the Royal College of General Practitioners. The event was aimed at ‘First Five’ general practitioners. I spoke on the topic of opportunities in research. The event was chaired by Dr Camille Gajria and Dr Nilesh Bharakhada. Other speakers at the conference included Dr Ian Goodman, Chair of Hillingdon CCG, who spoke on the topic of emerging opportunities for GPs through new models of care; Dr Sohail Hussain who spoke on media opportunities; Dr Krishan Aggarwal who spoke on finance; Dr Shivani Tanna who spoke on teaching opportunities; Dr Sonia Tsukagoshi who spoke on international opportunities; and Dr Nilesh Bharakhada who spoke on the Care Information Exchange and opportunities in technology for GPs. The event was a good opportunity for First Five GPs to learn about career opportunities in London and also update themselves on areas such as personal finance and key developments in the NHS in London, such as new care models.

Tobacco control efforts in the Gulf Cooperation Council countries

A paper published in the Eastern Mediterranean Health Journal  reviews the current state of tobacco use, governance and national commitment for control, and current intervention frameworks in place to reduce the use of tobacco among the populations of the Gulf Cooperation Council (GCC) member states and Yemen. It further reviews structured policy-oriented interventions (in line with the MPOWER package of 6 evidence-based tobacco control measures) that represent government actions to strengthen, implement and manage tobacco control programmes and to address the growing epidemic of tobacco use.

The findings of the review show that tobacco control in the GCC countries has witnessed real progress over the past decades. These are still early days but they indicate steps in the right direction. Future investment in implementation and enforcement of the Framework Convention on Tobacco Control, production of robust tobacco control legislation and the establishment of universally available tobacco cessation services are essential to sustain and strengthen tobacco control in the GCC region.

Why do patients attend general practitioner-led urgent care centres with minor illnesses?

The demand for urgent care is increasing, and the pressure on emergency departments is of significant concern. General practitioner (GP)-led urgent care centres are a new model of care developed to divert patients to more appropriate primary care environments. In a study published in the Emergency Medicine Journal, I along with colleagues from Imperial College London explored why patients with minor illnesses choose to attend an urban urgent care centre.

We used a self-completed questionnaire among patients aged 18 years or over (N=649) who were triaged with a ‘minor illness’ on arrival at an urgent care centre co-located with an emergency department in London. The median age of participants was 29 years. 58% (649/1112) of patients attending the centre with minor illness during the study period took part. 72% of participants were registered with a GP; more women (59%) attended than men; and the majority of participants rated themselves as healthy (81%). Access to care (58%) was a key reason for using the service as was expectation of receiving prescription medication (69%). GP dissatisfaction influenced 10% of participants in their decision to attend. 68% did not contact their GP in the previous 24 hours before attending.

We concluded that the GP-led urgent care centre was attracting healthy young adults, who were mostly registered with a GP and used services because of convenience and ease of access rather than satisfaction levels with their GP. An expansion of primary care capacity for patients with acute minor illnesses could reduce the number of patient who see their own practice rather than attend an urgent care centre.

Patients are more satisfied with general practices managed by GP partners than those managed by companies.

General practices in England are independent businesses that are contracted to provide primary care for specified populations. Most are owned by general practitioners, but many types of organisation are now eligible to deliver these services. In a study published in the Journal of the Royal Society of Medicine, we examined the association between patient experience and the contract type of general practices in England, distinguishing limited companies from other practices.

We analysed data from the English General Practice Patient Survey 2013–2014 (July to September 2013 and January to March 2014). Patients were eligible for inclusion in the survey if they had a valid National Health Service number, had been registered with a general practice for six months or more, and were aged 18 years or over. All general practices in England with eligible patients were included in the survey (n = 8017).

Patients registered to general practices owned by limited companies reported worse experiences of their care than patients registered to other practices on average. This applied to practices recorded as limited companies in routine contract data and to practices owned by large organisations. The sizes of the differences in experience varied from moderate to large across four outcome measures and were largest for the frequency of consulting a preferred doctor. Limited company ownership of general practices is uncommon in England. Patient experience was not consistently associated with the contract type for practices not recorded as limited companies. Across all contract and ownership types, patients generally reported positive experiences of their general practices.

Although our results suggest that limited companies provide worse patient experiences on average, some practices owned by these companies provide a good experience; others provide the opposite. It is the responsibility of commissioners, regulators, clinicians and owners to guarantee that individual practices meet expected standards while ensuring that care quality is not systematically associated with the ownership. Commissioners also need to ensure that contracts offer good value for money, more so at a time when the National Health Service is under severe financial pressure.

Reorganisation of stroke care and impact on mortality in patients admitted during weekends

In a study published in BMJ Safety and Quality, we evaluated mortality differences between weekend and weekday emergency stroke admissions in England over time. We aimed to determine whether a reconfiguration of stroke services in Greater London was associated with a change in this mortality difference.

We extracted patient-level data from national routinely collected administrative data (Hospital Episode Statistics or HES) from 1 January 2008 to 31 December 2014. Records include information of all admissions to English National Health Service (NHS) hospital trusts. Each patient record contains information on demographics (such as sex, age and ethnicity), the episode of care (such as trust name, date of admission) and diagnosis.

Our study covers a 30-month period before (January 2008 to June 2010) the reorganisation of stroke service in Greater London, and a 54-month period afterwards (July 2010 to December 2014). All admissions during the same period in the rest of England were used as controls.

Across England, the higher 7-day and 30-day in-hospital mortality risk associated with patients with stroke admitted during weekends compared with weekdays declined during the study period, to the extent that it was no longer statistically significant in the most recent year (2014). In Greater London, an adjusted 28% (RR=1.28, 95% CI 1.09 to 1.47) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 9% higher risk (RR=1.09, 95% CI 0.91 to 1.32) in 2014. For the rest of England, a 15% (RR=1.15, 95% CI 1.09 to 1.22) higher weekend/weekday 7-day mortality ratio in 2008 declined to a non-significant 3% higher risk (RR=1.03, 95% CI 0.97 to 1.10) in 2014. During the same period, in Greater London an adjusted 12% (RR=1.12, 95% CI 1.00 to 1.26) weekend/weekday 30-day mortality ratio in 2008 slightly increased to 14% (RR=1.14, 95% CI 1.00 to 1.30); however, it was not significant.

While other research has suggested that centralisation of stroke care in London is associated with better outcomes generally, we in addition observe a gradual reduction in the weekend effect for emergency stroke admissions across England between 2008 and 2014. Although we cannot rule out an effect from centralisation, we found no statistical association with the reorganisation of services in London. This is unlikely to be due to changes in casemix or coding, and is consistent with a more general pattern of service improvement across the country with increased specialisation, as well as improved 24/7 delivery of care. While we have not specifically looked at staffing levels, it has not escaped our notice that our observed reductions in the ‘weekend effect’ occurred before any contractual changes for medical staffing in the UK.

Public support for increased tobacco taxation in Europe is highest in more affluent counties

Increased taxation on tobacco products can be an effective method of reducing tobacco use. In a study published in the Scandinavian Journal  Public Health, Filippos Filippidis and myself, along with colleagues from Harvard University, assessed support for increased taxation on tobacco products and other tobacco control measures among people aged ≥15 years in 27 European Union (EU) during the period 2009-2012.

We obtained nationally representative data from the 2009 (n=26,788) and 2012 (n=26,751) cross-sectional Eurobarometer surveys. Estimates were compared using chi-square statistics. The effect of the relative change in gross domestic product (GDP) on the change in support for increased taxation during 2009-2012 was calculated using the Pearson correlation coefficient and linear regression models.

We found that between 2009 and 2012, support for increased taxes on tobacco products declined (56.1% to 53.2%. However, support for other tobacco control measures increased significantly. After adjusting for baseline GDP per capita (2009), a 10% increase in GDP per capita was associated with 4.5% increase in support of tax increases. There was a strong correlation between the change in GDP and support for increased taxes (correlation coefficient 0.64). Also, after adjusting for baseline GDP, support for higher taxes on tobacco increased by 7.0% for every 10% increase in GDP between 2009 and 2012.

We concluded that population support for tax increases declined in the EU between 2009 and 2012, especially in countries with declines in GCP. Nonetheless, public support for other tobacco control measures remains high, thus indicating a viable environment for the use of more comprehensive tobacco control policies.

How can medical students be encouraged to consider primary care as a career?

In a letter published in the British Journal of General Practice, medical students Fahmida Mannan and Zain Chaudhry from the Imperial College London School of Medicine discuss how the NHS and medical schools can encourage students to consider general practice as a career option. They suggest the focus in medical schools should shift towards improving the quality of general practice placements and promoting the integration of primary care and specialist teaching, rather than consuming more time in an already overstretched curricula.

They also consider that prestige has never been the main incentive for pursuing a specialty. Their own experience is that many medical students are attracted to a career in general practice because of other factors, such as a good work–life balance, continuity of care and career flexibility. With many GPs now concerned about their workload, this inevitably influences students and junior doctors in their career choices.

Another key factor is the funding that a specialty receives. In recent years, the proportion of the NHS budget spent on primary care has decreased, GPs’ workload has increased and the income of GPs has fallen. To recruit more GPs, medical schools should improve the quality of students’ experiences in their primary care placements. However by itself, this will not be sufficient to improve recruitment and the onus falls upon the NHS to once again make general practice a rewarding career for doctors.

We are now seeing some signs of this. For example, the NHS England Five Year Forward Strategy emphasises the importance of primary care to the NHS and proposes new employment models for general practitioners. This includes the formation of GP Federations in which general practitioners will come together to work in larger groups; and the possibility that hospitals could also employ GPs and offer primary care services.

Community Outreach in West London

Members of the School of Public Health held a very productive and informative meeting today with senior members of Imperial College including Sarah Waterbury, Vice President (Advancement); Maggie Dallman, Associate Provost (Academic Partnerships); Angela Bowen, Director of Development (Faculty of Medicine); and Tom Pearson, Head of Special Projects (Academic Partnerships).

The Department of Primary Care & Public Health in the School of Public Health works with local community stakeholders – such as voluntary groups, local authorities, and general practitioners – on a range of community-based outreach projects. These projects aim to improve the health and wellbeing of local residents; improve access to professional careers for children from deprived backgrounds; and give medical students experience of working with deprived and marginalised groups to develop skills in health coaching and behavioural change. This work is in addition to the very high-quality teaching and research programmes undertaken by the department.

Objectives for the future include developing a central coordinating function to bring this outreach work together; and integrate better with ongoing academic work in the Department of Primary Care and Public Health, the School of Public Health, the Faculty of Medicine, and Imperial College. We also need to expand the academic outputs from this work – such as conference presentations and journal articles – and give our students and clinical trainees greater opportunities to play a role in this work, thereby improving their skills and also the well-being of our local population.

 

Proportion of emergency admissions via A & E increasing while the proportion via GPs falling

In a paper published in the Journal of the Royal Society of Medicine, a team from Imperial College London examined time trends in emergency hospital admissions via accident and emergency departments in England. The proportion of emergency hospital admissions in which patients were admitted via an A and;E department increased markedly in England between 2001–2002 and 2010–2011.

There are several possible explanations for this trend. These include coding changes and the greater use of A and E departments to assess patients before they are admitted as emergencies. Changes in access to general practitioners – both during normal working hours and out of hours – may also have contributed to these changes.

The findings of the study in the JRSM are similar to those from studies in the United States. Future health policy should address gatekeeping in A  and E departments and the provision of urgent care in general practice  New models of care such as urgent care services that employ GPs in A and E departments as the gatekeepers to specialist urgent care may help in addressing this challenge but must be evaluated before they are scaled up.

The article was covered in Pulse and GP.

Electronic learning could enable millions more students to train as doctors and nurses worldwide

Electronic learning could enable millions more students to train as doctors and nurses worldwide, according to research carried out by the Department of Primary Care and Public Health at Imperial College London.

A review commissioned by the World Health Organization (WHO) and carried out by Imperial College London researchers concludes that eLearning is likely to be as effective as traditional methods for training health professionals.

eLearning, the use of electronic media and devices in education, is already used by some universities to support traditional campus-based teaching or enable distance learning. Wider use of eLearning might help to address the need to train more health workers across the globe. According to a recent WHO report, the world is short of 7.2 million healthcare professionals, and the figure is growing.

The Imperial team, led by Dr Josip Car, carried out a systematic review of the scientific literature to evaluate the effectiveness of eLearning for undergraduate health professional education. They conducted separate analyses looking at online learning, requiring an internet connection, and offline learning, delivered using CD-ROMs or USB sticks, for example.

The findings, drawn from a total of 108 studies, showed that students acquire knowledge and skills through online and offline eLearning as well as or better than they do through traditional teaching. The authors suggest that combining eLearning with traditional teaching might be more suitable for healthcare training than courses that rely fully on eLearning because of the need to acquire practical skills.

Dr Josip Car, from the Department of Primary Care and Public Health in the School of Public Health at Imperial College London said: “eLearning programmes could potentially help address the shortage of healthcare workers by enabling greater access to education, especially in the developing world the need for more health professionals is greatest.

“There are still barriers that need to be overcome, such as access to computers, internet connections, and learning resources, and this could be helped by facilitating investments in ICT. Universities should encourage the development of eLearning curricula and use online resources to reach out to students internationally.”

The full text of the review can be viewed online.

News items on the report were published in the Nursing Times and in the Examiner as well as by Reuters.