Blog posts

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

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

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

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

Improving workplace health in the NHS

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

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

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

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

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

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

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

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

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

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

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

Case fatality in Covid-19 (Coronavirus) infection

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

Sepsis: getting the balance right

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

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

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

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

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

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

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

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

Digital health: A greater focus on human factors is needed

There is growing appreciation that the success of digital health – whether digital tools, digital interventions or technology-based change strategies – is linked to the extent to which human factors are considered throughout the design, development and implementation. A shift in focus to individuals as users and consumers of digital health highlights the capacity of the field to respond to recent developments, such as the adoption of person-centred care and consumer health technologies.

In an article published in the journal BMC Medicine, we argue that this project is not only incomplete, but is fundamentally ‘uncompletable’ in the face of a highly dynamic landscape of both technological and human challenges. These challenges include the effects of consumerist, technology-supported care on care delivery, the rapid growth of digital users in low-income and middle-income countries and the impacts of machine learning.

Digital health research will create most value by retaining a clear focus on the role of human factors in maximising health benefit, by helping health systems to anticipate and understand the person-centred effects of technology changes and by advocating strongly for the autonomy, rights and safety of consumers.

Digital Education in Health Professions: The Need for Overarching Evidence Synthesis

Synthesizing evidence from randomized controlled trials of digital health education is challenging. Problems include a lack of clear categorization of digital health education in the literature; constantly evolving concepts, pedagogies, or theories; and a multitude of methods, features, technologies, or delivery settings.

The Digital Health Education Collaboration was established to evaluate the evidence on digital education in health professions; inform policymakers, educators, and students; and change the way in which these professionals learn and are taught. In a paper published in the Journal of Medical Internet Research, we presented the overarching methods we use to synthesize evidence across our digital health education reviews and to discuss challenges related to the process.

For our research, we followed Cochrane recommendations for the conduct of systematic reviews; all reviews are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidance. This included assembling experts in various digital health education fields; identifying gaps in the evidence base; formulating focused research questions, aims, and outcome measures; choosing appropriate search terms and databases; defining inclusion and exclusion criteria; running the searches jointly with librarians and information specialists; managing abstracts; retrieving full-text versions of papers; extracting and storing large datasets, critically appraising the quality of studies; analyzing data; discussing findings; drawing meaningful conclusions; and drafting research papers.

The approach used for synthesizing evidence from digital health education trials is the most rigorous benchmark for conducting systematic reviews. Although we acknowledge the presence of certain biases ingrained in the process, we have clearly highlighted and minimized those biases by strictly adhering to scientific rigor, methodological integrity, and standard operating procedures. our paper will be a valuable asset for researchers and methodologists undertaking systematic reviews in digital health education.

Is it getting easier to obtain antibiotics in the UK?

In the UK, antibiotics are, with very few exceptions, only prescribable by doctors or other health professionals with prescribing qualifications. This has meant that, until recently, access to antibiotics has been possible only through face-to-face medical assessment in primary or secondary care, providing a significant disincentive to seeking antibiotics unnecessarily.

Inappropriate prescribing of antibiotics in UK primary care remains of concern, but antimicrobial stewardship initiatives are having a measurable effect, with prescribing rates falling in response to interventions. However, novel routes to obtaining antibiotics, associated with either a lower threshold for prescribing or issuing of antibiotics without medical assessment, undermine these strategies and are likely to increase inappropriate use.

These issues are discussed further in an article published in the British Journal of General Practice.

Type 2 Diabetes in Children and Young Adults

Newly published statistics show that nearly 7,000 children and adults aged under 25 in the UK have been diagnosed with type 2 diabetes. The onset of Type 2 Diabetes is strongly associated with lifestyle factors such as obesity, lack of exercise and high calorie (high sugar) diets. In recent decades, countries such as USA and UK have seen large increases in the number of people with type 2 diabetes. Most of these cases have been among older people but we are now also seeing an increasing number of cases of Type 2 Diabetes among younger people.

Reversing the increase in Type 2 Diabetes is not easy. It requires action by individuals, and also by governments and societies. For individuals, it is important that people eat a healthy, balanced diet that is not too high in calories, and not high in refined carbohydrates and sugars. Dietary changes need to be combined with regular exercise to keep weight down to healthy levels, thereby reducing the risk of developing type 2 diabetes.

A number of people with established type 2 diabetes have reversed their condition through measures such as dieting and exercise. This shows even if an individual has Type 2 Diabetes, they can resolve this through appropriate lifestyle measures.

Measures taken by individuals need to be backed by measures targeting the entire population. This can include for example, ‘sugar taxes’ on high-calorie drinks to encourage individuals to consume them less and to encourage manufacturers to produce lower calorie version of these drinks. Calorie labelling of food can also help people make suitable choices about their diets. We also need measures to encourage physical activity, for example, making it easier and safer for people to cycle and walk rather than using cars.

It’s important that regular exercise and healthy diets are introduced at a young age. Hence, nurseries, schools, colleges and universities also have an important role to play in addressing the causes of Type 2 Diabetes.