Patients with a FIT of fHb <10μg Hb/g, a normal full blood count, and no ongoing clinical concerns do not need to be referred on a lower GI urgent cancer pathway but can be managed in primary care or referred on an alternative pathway with suitable safety netting if symptoms change. FIT can improve patient management. By fully implementing the use of FIT in people with lower GI symptoms in primary care, we can spare patients unnecessary colonoscopies, releasing capacity to ensure the most urgent symptomatic patients are seen more quickly in specialist clinics. There are some patients for whom FIT is not suitable, such as those with iron deficiency anaemia, a rectal or anal mass, or anal ulceration. See below for further guidance on the use of FIT in people with lower GI symptoms. British Society For Gastroenterology NHS England
Dr Anthony Laverty, members of the Public Health Policy Evaluation Unit and Parris Williams from NHLI hosted a stall at the most recent Imperial Lates event which was themed around drug experiments.
The team had an interactive stall where members of the public could share their views and ideas on how we could reduce smoking in the UK as well as voting on their preferred solutions. They also gave a “tiny dose of science” talk on the public health implications of e-cigarettes. Images courtesy of Brendan Foster Photography
WHAT NEEDS TO BE DONE TO ADDRESS STAFFING SHORTAGES IN HEALTH AND SOCIAL CARE? Our article in the British Journal of General Practice discusses the importance England’s NHS having an effective workforce strategy. Staffing shortages in health and social care are limiting the delivery of services. Interventions to improve the recruitment and retention of staff, along with also improving staff wellbeing, are essential. Health and social care organisations must invest in understanding what works to recruit and retain staff, and, in the case of general practice, in patient- facing roles. NHS Employers suggests target areas for focus for employing organisations, such as encouraging flexibility and supporting new starters; however, there is a lack of evidence on what is proven to keep people in post, recently highlighted by the Royal College of Anaesthetists concerned about staffing levels within their own specialty. Financial incentives including pay, taxation, and pensions must be optimised but do not exonerate the need to optimise working conditions. Outcomes of health, wellbeing, and support initiatives such as patient safety, staff turnover, sickness absence, and financial impact should be analysed and shared across organisations. Local and national retention programmes should involve staff, patients, and occupational health. Looking after the workforce in all health and social care settings will improve productivity and staff retention as well as providing safer care for patients.
There has been an increase in Group A Streptococcal (GAS) infections in recent months, which has led to at least 8 deaths in children. Although GAS rates are higher than expected for this time of year, they have been higher at periods over the last decade. GAS causes a range of infections including Scarlet Fever and also more severe invasive disease. For more information on management, see: Scarlet fever: a guide for general practitioners. The Centor score can be used to assess the probability of an illness being GAS pharyngitis: Tonsillar exudates, tender anterior cervical adenopathy, absence of cough, history of fever (>38 °C). Penicillin V (or Amoxicillin) is the preferred treatment unless contra-indicated in which case an alternative such as a cephalosporin or clarithromycin can be given. Scarlet Fever and invasive GAS disease are notifiable and should be reported to the local health protection unit. Contacts (although at higher risk of GAS infection) do not generally need antibiotics unless symptomatic. See contact tracing flowchart for details. Health protection teams are responsible for contact tracing. This guidance was updated in 2008 and may change again. Antibiotics should only be administered: 1. To mother and baby if either develops invasive group A streptococcal disease in the neonatal period (first 28 days of life). 2. To close contacts if they have symptoms suggestive of localised Group A streptococcal infection, i.e. sore throat, fever, skin infection. 3. To the entire household if there are two or more cases of invasive group A streptococcal disease within a 30-day time period. Oral Penicillin V is the drug of first choice where chemoprophylaxis is indicated. Azithromycin is a suitable alternative for those allergic to penicillin. Some areas of England are now reporting shortages of liquid antibiotics. FURTHER READING Group A streptococcal infections in the UK
By Professor Azeem Majeed There has been considerable recent debate about charging for GP appointments after comments from two former UK health secretaries, Kenneth Clarke and Sajid Javid, elicited strong responses both for and against user fees. Let’s try to put aside ideology and emotion and look objectively at the evidence and arguments around user fees in NHS primary care.
Debates over NHS user fees are not increase expectation of a “return on new. In 1951, Hugh Gaitskell investment.” Doctors may feel introduced charges for prescriptions, pressure to provide prescriptions and spectacles, and dentures. Aneurin referrals, or carry out investigations, to Bevan, minister for labour and satisfy patients who have paid to see architect of the NHS, resigned in them. User fees may also result in protest at this abandonment of the patients hoarding health problems, principle of NHS care being free at the with clinicians expected to tackle more point of need. Many developed health concerns in the typical 10–15- countries already charge users to minute appointment in general access primary care services, often practice. Flat-rate user fees might also through a flat-rate co-payment. introduce a financial barrier to However, there is a lack of evidence healthcare access for people with a about the impact of such fees on low income, potentially widening access to healthcare, health health inequalities. inequalities, and clinical outcomes. A key study on the impact of user fees The highest users of primary care, such in a high-income country (the RAND as women seeking maternity care, and Health Insurance Experiment) is now those aged under 5 or over 65 years, nearly 40 years old. are also among the group that would probably be exempt from user fees. If User fees should theoretically people with a low income are also encourage patients to act prudently exempted from fees, we may see little and so reduce “unnecessary” or reduction in GP workload, and only “inappropriate” use of healthcare. modest additional revenues for the Some European countries with user NHS—particularly when offset against fees for primary care have indeed seen the costs of collecting fees, including lower rates of healthcare utilisation. chasing patients for any unpaid fees. But this theory is based on the assumption that patients can safely Wealthier patients, when asked to pay and effectively distinguish between for NHS GP appointments, may opt for necessary and unnecessary care. In private primary care instead, further reality, preventive care and chronic increasing health inequalities and disease management are both likely to leading to the fragmentation of care. decline when fees are in place, with Such an environment could cause patients often delaying presentation private primary care services to until costly medical crises occur. expand, increasing shortages of NHS GPs if more GPs choose to work in the Expectations about what the UK NHS private sector. should offer are already high among the public, and user fees may further The collection of user fees would require new billing and debt collection
systems across all NHS general example, charging a fee for attending practices. To safeguard vulnerable A&E. people, it would be necessary to create exemptions, which would reduce UK residents benefit from a high level revenue and further add to of financial protection from the costs administrative costs. After exemptions, of illness. Accustomed to free primary user fees would probably only be care for many decades, the public is collected from a relatively small likely to resist such fees strongly. As a section of the population. For example, result, any political party that around 90% of NHS primary care advocated NHS user fees may pay a prescriptions in England are dispensed high price at a general election. free of charge and revenues from prescription charges cover only a small Valid arguments exist for and against percentage of the actual cost of NHS introducing primary care user fees. drugs. User fees are promoted by some commentators as a remedy to current User fees may also lead to false NHS challenges in areas such as economies if they deter people from funding and workload. Yet primary accessing primary care when they care workload and NHS deficits are should, resulting in costly delayed also symptoms of deeper problems, diagnoses (for example, for cancer), or such as shortages of clinical staff and lead people to seek care only for acute reactive, fragmented care. problems, deprioritising important Consequently, user fees by themselves preventive and chronic care. won’t be the solution to problems that have proven intractable for the NHS to User fees will also be ineffective if they solve. divert costs to other parts of the NHS such as accident and emergency We do, however, need to look at what departments or urgent care centres. In services we expect NHS general the USA, for example, user fees have practices to provide and how we fund led to “offsetting” of costs, with these services. This will include increased hospital admissions and use reviewing the current employment of acute mental health services. models of NHS GPs. If governments in Patients may therefore choose to use the UK do not want to fund NHS GP services that are “free” to the user but services adequately, user fees of some expensive to the system, such as kind (perhaps for “add-on” but not for emergency care. A coherent policy core primary care services) or two-tier would require simultaneous setting of primary healthcare may be inevitable fees in related areas of the NHS—for outcomes. Source: Azeem Majeed. Let’s look dispassionately at the arguments for and against user fees for NHS primary care in England, BMJ
MULTIDISCIPLINARY TEAM MEETINGS TO MANAGE PATIENTS WITH MULTIMORBIDITY IN PRIMARY CARE
Our recent paper in the International Journal of Integrated Care reviews the role of multidisciplinary team (MDT) meetings in the management of multimorbidity in primary care. MDTs bring together professionals to work together to improve health outcomes for patients. MDT meetings are often recommended as a critical aspect of integrated care in guidance and opinion pieces, but it is not clear how and to what extent their use improves outcomes for patients with multimorbidity. Our review aimed to fill this knowledge gap. We found limited evidence that that causality cannot be attributed supports the implementation of to the MDT meeting alone. MDT meetings in primary care settings for individuals with There is an urgent need to generate multimorbidity. There were also more evidence about MDT meetings substantial problems with the in primary care. Future research methodological rigour of previous should focus on a broader set of studies on MDT meetings in primary participant characteristics, care. Although MDT meeting are a contextual adaptation, and key strategy for delivering innovation. Decision makers and comprehensive integrated care, clinicians should also take there is a lack of evidence advantage of the recent concerning the efficacy of MDT technological progress in meetings in primary care. The healthcare. complexity of interventions meant Photo by Nappy on Unsplash
Five minutes with… ProfessorJennifer Quint Respiratory EHR Group
What is your role within the department and how long have you been here? I’m a Professor of Respiratory Epidemiology and lead a research group who use various different sources of routinely collected electronic healthcare record data to study respiratory diseases. I have been here since May of last year, having been part of NHLI previously. What does your role involve? I’m a clinician by background and spend 20% of my time doing clinical work. The rest of the time I am either doing research or involved in teaching. Why PCPH? Because everyone here is amazing! What do you enjoy most about your role? The unknown, the flexibility, the fact that no two days are the same and enthusing people about coding and data! What were you doing prior to this? I trained as a doctor and did a lab-based PhD whilst doing my specialist respiratory training. I enjoyed research but wasn’t as good as the scientists in the lab so went and did a MSc in Epi at LSHTM after my PhD as part of a postdoc fellowship and started working with healthcare data.
Image by rawpixel.com
Tell us about your outside interests Most of my ‘outside’ life is taken up by being a wife and a mum. When I get the chance, I love running, cooking and traveling. I have 3 cats that I’m allergic to, but my husband and daughter refuse to get rid of them. What are your goals for the next few years? Not turn grey whilst my daughter does her GCSEs and A levels and hopes she gets into university somewhere! You’re to be marooned on a desert island – which 3 people (real or fictional, dead or alive) would you choose to be marooned with. What luxury item would you take with you and what three tunes would you take with you? Jack Sparrow, Albert Einstein and John Snow. My luxury item would be my electric toothbrush. My three tracks would be: • Maroon 5 – Girls Like You • Tim McGraw – Live Like You Were Dying • PINK – So What
Search
