December 2021 Department of Primary Care & Public Health What are the real reasons why General Practice is in crisis? Image by vecteezy.com
December 2021 We are now nearly two years from March 2020 when Imperial College switched to remote working because of the Covid-19 pandemic. It has been a difficult time personally and professionally for staff and students. Most staff continue to work remotely; but we are trying to carry out more teaching face to face. With the booster Covid-19 vaccine programme showing excellent results, we are increasingly optimistic we may see a gradual return to a more normal way of living and working in 2022. Members of the department and the NIHR ARC Team have played an important role in the local and national response to Covid-19; a role that will continue in 2022. Many thanks for everyone’s contribution. Finally, I would like to wish all members of the Professor Azeem Majeed department and their families a merry Christmas and a happy New Year. Enjoy the Head of Department of Primary Care and Christmas holiday with your family and Public Health friends. Imperial College London Follow Prof Majeed on Twitter We welcome feedback on the ARCHIVE PRIVACY NOTICE newsletter and are taking submissions for future issues. Email your news, events, achievements and stories to us. [email protected] PCPH eMagazine is Subscribe Unsubscribe produced by Javier Gallego Copyright © 2021 Department of Primary Care & Public Health, Imperial College London
The government’s chief medical officer says he will continue to wear a face mask when appropriate. We should follow his example. Covid-19 is an infection that is largely spread indoors – particularly in crowded, poorly ventilated areas – through inhaling droplets and aerosols produced by infected people when they cough, sneeze, sing, talk, or breathe. Face masks are a simple method of reducing the risk of infection – but only if they are worn by large numbers of people. The main function of a mask is to reduce the emission of droplets from infected people into the air. The droplets are captured by the mask and hence less virus enters the air. Much of the benefit of wearing face masks goes to other people but they can also benefit the wearer, particularly if a high-specification FFP2 mask is worn that filters out more particles and droplets when the wearer breathes in air. Wearing face masks will reduce the spread of the coronavirus and help protect others. This is very important in settings where we are in contact with older and more vulnerable people – such as in supermarkets and on public transport. Wearing a mask has no major side effects, and does not change a person’s oxygen or carbon dioxide levels. Widespread wearing of face masks has been an important part of the pandemic control strategies of countries that have been more successful in containing the spread of Covid-19. Vaccines are essential and can protect us from developing a more serious illness. But we must maintain the use of other control measures, such as the use of face masks, until we are past the worst of the Covid-19 pandemic. Photo by Haithem Ferdi on Unsplash
FELLOWSHIP CEREMONY - ROYAL COLLEGE OF PHYSICIANS The Royal College of Physicians held its first Fellowship ceremony since the Pandemic began on 29 September. Dr Elizabeth Muir was made a Fellow of the College in 2020, supported by Professor Azeem Majeed. Elizabeth’s innovative teaching of undergraduate medical students at Imperial and her support of Carers in the UK and across Europe were recognised. Professor Jonathan Van-Tam was awarded an honorary fellowship at the event making the celebration very special. GRANT & FELLOWSHIP AWARDS Thomas Beaney has been awarded a 3-year clinical PhD fellowship from the ‘Wellcome 4i’ The Royal College of Paediatrics and Child programme at Imperial, starting in December Health has awarded funding to Dr Dougal 2021. Tom currently works as a GP in White Hargreaves, Clinical Senior Lecturer, and Dr City and in digital health in PCPH and ARC Rakhee Shah, Clinical Research Fellow, at the NWL, having completed an academic clinical Child Health Unit to investigate variations in fellowship in primary care in the department in epilepsy outcomes for children and young February. Tom will be based jointly in PCPH people in England. Paediatric hospital and the Department of Mathematics, catchment populations will be estimated for all supervised by Prof Aylin, Prof Majeed, Prof NHS acute Trusts in England. Expected rates of Barahona, and Dr Woodcock. His PhD will look new epilepsy diagnoses and epilepsy-related at understanding multimorbidity and its admissions for each Trust will be calculated associations with clinical outcomes and based on catchment population, and these healthcare utilisation. rates will be compared to observed rates. Observed rates of epilepsy diagnoses will be Much of the existing literature on obtained from the national paediatric multimorbidity looks cross-sectionally, defining Epilepsy12 clinical audit and observed rates of multimorbidity as simple counts of number of epilepsy-related admissions will be obtained long-term conditions. While certain clusters of from Hospital Episode Statistics. NHS Trusts concordant diseases are well-characterised, with larger than expected variation between such as the links between cardiovascular observed and expected values will be looked at disease and diabetes, other as yet unknown to identify modifiable health service factors. disease clusters may have shared aetiology and present opportunities for early Dr Shah has also been awarded the Royal intervention and better configuration of Society of Medicine Sam Tucker Fellowship for healthcare services to support people with her academic record of achievement in multimorbidity. Using national and regional Paediatrics and Child Health. She will become a primary and secondary care linked datasets, member of the Paediatrics & Child Health the PhD will aim to characterise patterns in Council from 1 October 2021 until 30 both the combination of diseases and in the September 2023 and will receive £250. Dr sequence and trajectory of disease Shah’s work is aimed at improving outcomes development, using natural language for children and young people by using health processing and unsupervised clustering services research to influence health policy at a approaches. national level.
SELF-CARE WEEK Self-Care Week this year was 15-21 November and is the annual UK-wide national awareness week that focuses on embedding support for self-care across communities, families & generations. The theme this year is Practise Self-Care for Life. Self-Care Forum UK has produced free resources to help with planning activities including an 8 Point Plan. SCF also produced a series of fact sheets which are available to download, including one on Long COVID/Post COVID Syndrome. Take a look at the website or get in touch with the charity for more details at [email protected] To keep updated, you can subscribe to the SCF newsletter or follow them on Twitter: @Selfcareforum. FACULTY OF PUBLIC HEALTH PRESIDENT’S MEDAL Dr Richard Pinder was awarded the President’s Medal of the Faculty of Public Health by Prof Maggie Rae in September 2021 recognising his “outstanding contribution to Public Health” since the start of the pandemic. On top of his usual job leading the UG Public Health team at Imperial, Richard has been providing health protection leadership in southeast London, and continued as an Associate Editor of the Journal of Public Health and as the national assessment lead for public health specialty training.
VIDEO PASSPORT APP TRIAL EMERGENCY PREPAREDNESS The Mirror reported that “more than 14,000 Over the past two years, the pandemic has music fans filmed themselves taking Covid shown us that the health systems need a more tests so they could get into a festival, as part of comprehensive and unique approach to train a scheme using video to get into mass its workforce in public health concepts, events…Clips were uploaded onto an app, specifically in emergency preparedness, which were then verified to make sure planning, and response. The public health ticketholders were being honest and had done workforce encompasses a broad education and the swab correctly…Dr Jack Kreindler, training background, representing the Honorary Research Fellow at PCPH and functions taken on at work across many medical director of Certific, the company that ministries, institutions, community carried out the verification - said he was organisations, and the private sector. Celine surprised that it met little resistance among Tabche presented a poster on ‘Emergency those attending the festival, saying it is a sign Preparedness and Planning Training Courses – people do want to help each other out.” Need and Delivery During a Pandemic’ at the WHO regional meeting in October. FULL ARTICLE FAREWELL PIRKKO! In September, several PCPH staff and students gathered for an in person farewell lunch for Pirkko Carmack. Pirkko has been part of our administration team for 8 years and during that time became a highly regarded member. Azeem led by thanking her for her work and support and in wishing her well in future. Congratulations on your retirement, Pirkko!
A QUEST TO IMPROVE MENTAL HEALTHby MPH Student Ms Reda Misghina DIAGNOSIS AMONG THE DEAF COMMUNITY IN THE UK by MPH Student Ms Reda Misghina
Each year in the UK, at least 1 in 4 people experience a mental health problem.[1] When faced with a mental health illness, we often hear the words ‘it helps to talk about it’. The tool of communication in Deaf individuals makes it so that ‘talking’ takes a different format in their ability to convey thought. Various misconceptions about Deafness and the obstacles faced to access mental health services must then be conceptualised differently. Image by rawpixel.com
DEAFNESS AS AN IDENTITY complexity of Deafness. The Deaf identity is therefore not a “static concept but an In the UK, around 10 million people are ongoing quest for belonging”.[4] considered to be Deaf.[2] The heterogeneous forms of what it means to The British Sign Language (BSL) is a be Deaf renders it a complex subject. language in its own right, being the 4th Forms of identification is an interesting most used language in the UK. This factor. For example, there is a distinction language uses a different grammar and between a deaf person (lower case ‘d’) syntax to spoken English. Different signs which refers to those with severe hearing come with different facial expressions – problems or who became hard of hearing this may give an agitated impression to a later in life, compared to a Deaf person hearing person but are very important (capital ‘D), referring to people that were expression of emotions. For instance, a born deaf or became so soon after birth. common misconception is the assumption that Deaf people can read lips or have a Research over the years has noted a fluent English understanding. Recognising cultural distinction in identity the intrinsic nature of Deaf identity is thus formation. The Deaf Identity a step towards how Deaf people are Development Scale (DIDS) measure was understood in public health. The delivery developed to illustrate the psychological of vital mental health services should then process by which Deaf people orientate engage with the cultural and linguistic themselves with the Deaf culture and factors that define the Deaf population. community.[3] The various distinctions between multivariate methods of health care give way to misdiagnosis of identification give a notion of the mental illnesses. Research has established that standardised mental health DEAFNESS AND MENTAL HEALTH assessment designed for hearing people is often invalid for Deaf patients.[6] One of The size of the problem of Deaf people the few studies that has analysed with mental health issue is currently psychotic disorders in the US has shown unknown. There are various estimates that there are significant differences in that will paint a picture of the extent of its treatment and assessment of Deaf people severity but reliable evidence is either compared to the hearing population.[7] preliminary or out of date. It has been Assessment of cognitive functioning of a widely acknowledged that Deaf people Deaf patient needs to incorporate the are twice as likely to have mental health complexity of what the ‘Deafness’ really issues as hearing people and 40% of Deaf means. The degree of emotive behaviours people will experience a mental health expressed by Deaf people needs to be issue at some point in their lives.[5] well understood in order to provide quality mental health services. An up-to-date epidemiological study with a clear focus on the mental health of Deaf people is very much needed to identify the depth of the issue. Furthermore, lack of recognition of linguistic and cultural distinctiveness of Deaf people in primary
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GOING BEYOND THE LANGUAGE FIX Nonetheless, despite its growing recognition in public health, there is an Translating the conceptual theory of the inconsistency in our way of implementing Deaf identity and Deaf mental health into appropriate services that are essential for practice as a public health matter is a Deaf people, challenge yet to be fully met. Community- especially based mental health for the Deaf BSL users. community has been led by charities acting on behalf of primary and secondary Innovations such as the Austrian example mental health services. Currently, give guidance to how secondary care can SignHealth is the only Deaf health charity combine mental health in outpatient that offers a psychological therapy service clinics while the Healthy Minds initiative for Deaf people with ‘BSL Healthy Minds’. can be developed further to create an This essential service has helped connect integrated, patient-focused and identity patients to a Deaf therapist, or a hearing sensitive services and seek to go beyond but fluent BSL user done in the effort of the language fix. Therefore, identifying addressing the gap found in primary mental health. Additionally, Deaf people in large parts of the country are victim of ‘postcode lottery’ in accessing specialised community services. Due to low density of Deaf people residing and seeking the service in each Clinical Commissioning Groups (CCGs)-managed area in England, the Healthy Minds programme has referral numbers that are too high to be considered specialist and too low for CCGs to consider commissioning.[8] This move reinforces health inequality by an already marginalised community in primary and secondary mental health care. Effective management of ensuring mental health in a culturally sensitive way should allow space for innovation at a local and national level. Lessons could also be drawn from other countries. In Austria, for instance, Health Centres for the Deaf are an integrated part of primary and secondary care where they are supported by competent staff who are familiar with Deaf culture and are able to communicate in Sign language.[9]
BSL as a language and Deafness as an health challenges faced by Deaf people in identity is critical for mitigating the mental England. CONCLUSION national level. Recognising the cultural distinctiveness of the Deaf community is a In order to close the gap between mental pre-requisite to how medical and public health issues and medical services it is health professionals can assess their need paramount to conduct interventions at a for effective response. local level and start to implement BSL friendly psychological services at a This essay was awarded a prize by the Royal Society for Public Health. REFERENCES: 1. Mind. How common are mental health problems? [Internet]. Mind.org.uk. 2017. Available from: https://www.mind.org.uk/information- support/types-of-mental-health- problems/statistics-and-facts-about-mental- health/how-common-are-mental-health- problems/#one, [cited 3 November 2017] 2. Levine J. Primary care for deaf people with mental health problems. British Journal of Mental Health Nursing. 2014;3(3):105-109. 3. Glickman N, Carey J. Measuring deaf cultural identities: A preliminary investigation. Rehabilitation Psychology. 1993;38(4):275-283. 4. Hauser PC, O’Hearn A, McKee M, Steider A, Thew D. Deaf epistemology: deafhood and deafness. Am Ann Deaf 2010; 154: 486–96. 5. SignHealth. Executive briefing on mental health services for deaf and hard of hearing people [Internet]. Signhealth.org.uk. 2014 [cited 21 November 2017]. Available from: https://signhealth.org.uk/wp- content/uploads/2014/02/ExecutiveBriefing.pdf 6. Brauer BA, Braden JP, Pollard RQ, Hardy-Braz ST. Deaf and hard of hearing people. In: Sandoval J, Frisby C, Geisinger KF, Scheuneman J, Ramos Grenier J, eds. Test interpretation and diversity; achieving equity in assessment. Washington, DC: American Psychological Association, 1998: 297–315. 7. 1. Diaz D, Landsberger S, Povlinski J, Sheward J, Sculley C. Psychiatric disorder prevalence among deaf and hard-of-hearing outpatients. Comprehensive Psychiatry. 2013;54(7):991-995. 8. Hulme C. Can a Deaf charity develop an effective relationship with over 200 CCGs?. British Journal of Healthcare Management. 2015;21(10):452-455. 9. Fellinger J, Holzinger D, Schoberberger R, Lenz G. Psychosocial characteristics of deaf people: evaluation of data from a special outpatient clinic for the deaf. Nervenarzt 2005; 76: 43–51 (in German).
SPOTLIGHT ON
Building the evidence base for the harmful health and environmental effects of ultra-processed foods The PHPE team has made substantial contributions to accumulating evidence on the harmful effects of ultra-processed food (UPF) consumption on health and its potential environmental impacts. Their research studies using the UK Biobank database, a large cohort study of middle-aged British adults, demonstrated an increased risk of unhealthy weight and type 2 diabetes associated with higher UPF consumption, reporting these associations for the first time from the UK population.
These findings have been published in the European Journal of Nutrition and Clinical Nutrition respectively. In a similar study based on the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort with participants recruited from 9 European countries, they found higher UPF consumption was associated with greater weight gain and detailed study findings are now available in Clinical Nutrition. The team conducted the first large May 2021. Professor Millett explained longitudinal study assessing the impacts the dietary transition of UK families since of UPF consumption on adiposity in 1980 and how consumption of UPFs has children. They found that English children increased rapidly and gradually displaced with higher consumption of UPFs during our traditional dietary patterns based on childhood were associated with more minimally processed foods and freshly rapid progression of body mass index prepared meals. The programme is (BMI), fat mass index, weight and waist currently available on BBC iPlayer. circumference trajectories from 7 to 24 years of age. This study was funded by The team has two large ongoing the NIHR School of Public Health programmes of work funded by the Research (SPHR) and was a collaborative Cancer Research UK and the World work between researchers at the Cancer Research Fund. They are working University of Sao Paulo, Inserm and the with researchers at WHO IARC and the WHO International Agency for Research University of Sao Paulo to investigate the on Cancer (IARC). The article has been link between UPF consumption and published in JAMA Pediatrics and cancer risk, and the potential underlying received an extensive media interest. mechanistic pathways e.g. through obesity, using two large European cohort Considering the role of UPFs in wider studies - the UK Biobank and EPIC. food system network, the team published a commentary article ‘The The team has also made important neglected environmental impacts of contributions to a proposal to address ultra-processed foods’ in Lancet Action Track ‘shift to sustainable and Planetary Health. They highlighted the healthy consumption patterns’ ahead of potentially sizable environmental the United Nations’ Food System Summit impacts associated with UPFs that have which is scheduled to take place later in not been properly evaluated and the year. The proposal highlights the emphasised the urgent need for more urgent need for more radical and effective food system policies to reroute effective public health actions to raise dietary patterns of the population awareness of the harmful effects of towards dully healthy and sustainable. UPFs, to reduce the supply of UPFs and to increase access and affordability of The team also celebrated Prof fresh and minimally processed foods. Christopher Millett’s contribution to a These were summarised in a BBC documentary ‘What Are We Feeding commentary article published in BMJ Our Kids?’ which was broadcast on 27 Global Health.
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CONVERSATIONS AND CONSENT Since the chief medical officers (CMOs) recommended that all teenagers aged 12-15 should be offered one dose of the Pfizer-BioNTech vaccine, there has been much debate about the risks and benefits. Parents and teens WhatsApps have been filled with discussions, with many questioning what would happen if a parent wanted their teen to have the vaccine, but their teen refused, or vice versa. For the Child Health Unit’s BMJ editorial published in July on this topic, we involved parents and teenagers. The case for offering covid-19 vaccines to have occurred, more commonly affecting healthy teenagers is less compelling than boys and after second doses. Though for routine childhood vaccines, which myocarditis can occur with natural Covid- have direct individual benefits and years 19 infection it was this more serious of safety data. The health benefits of vaccine side-effect that led the CMOs to covid-19 vaccines are small for teenagers recommend only one dose. however, the CMOs decision was influenced by the wider benefit of Parents will be asked for consent, but reducing further education disruption. children under 16 with capacity to Covid-19 vaccines may also protect understand the risks and benefits can against persistent symptoms which occur provide their own consent. NHS in a small percentage of teenagers. professionals in the school immunisation service and primary care must have Most adolescents aged 12-15years protected time to facilitate informed vaccinated worldwide report minor short- conversations with teenagers and families lived side-effects such as injection site and whatever they decide, their views pain. However, a few cases of myocarditis must be respected. See also: Majeed A, Hodes S, Marks S. Consent for covid-19 vaccination in children BMJ
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What are the real reasons why General Practice is in crisis? A recent article in the Daily Telegraph asked, “If the GPs went on strike, would anybody notice?” The article claimed that no one would notice if GPs went on strike and the author suggested that making all GPs salaried, forcing them to work longer hours, would help improve general practice for patients. The author quoted “a now retired GP in his 90s from Bristol who continued doing locum work until five years ago,” who apparently said, “Many GPs are using covid-19 as an excuse for not providing good clinical services. Being able to opt out of night/weekend cover and only working two or three days a week have caused the demise of general practice to the detriment of patients.”
As GPs we have worked throughout from patients unable to access vaccine this pandemic often face-to-face in the appointments. most basic of personal protective equipment (PPE), and we were If we look at prescriptions, GPs and their disheartened to read this piece. teams issue a vast number every year. If another part of the NHS tried to take on GPs and their teams have played an this work, an army of people would be essential role throughout the pandemic. needed—doctors, pharmacists, and GP teams in England alone deal with administrative staff. Many higher risk over 300 million contacts each year. medications need careful monitoring General Practices have been running and regular review. Patients on most community hot covid clinics, and regular medication also require supporting NHS 111 and the Covid medication reviews, checks (e.g., blood Clinical Assessment Service (CCAS). We tests, measuring blood pressure) to are supporting 5.5 million patients on monitor safe prescribing and prevent NHS waiting lists, who are often in drug interactions, and to deal with severe pain and in need of extra queries and frequent shortages and support, as well as supporting about 1 changes of medicines. The efficient million patients with the effects of long systems that GPs have developed for covid, and adapting to new ways of prescribing means that they issue many working enforced by a global pandemic. prescriptions that would be given by In addition, our teams have delivered hospital specialists in other countries. the majority of covid vaccinations thus far. We are currently being asked to Moreover, every patient seen in recall our most clinically vulnerable secondary care generates a letter, often patients for their third covid booster with requests for GP teams to follow up vaccination. All this has been achieved patients, monitor their treatment, despite the proportion of the NHS arrange blood tests, or prescribe. budget spent on NHS general practice and the number of GPs per person both The work of a GP can be incredibly declining in England in recent years. rewarding as we build long term relationships with people over years, We are already seeing that any small and there is strong evidence for the reduction in GP access causes rapid spill benefits of continuity of care (for both over into Emergency Departments, so patients and the care provider). GPs are just imagine if there were no GP service true “generalists” and the uncertainty of at all. The NHS would collapse. When undifferentiated illness is stressful, GPs began to pull back from the covid- especially when working remotely. GPs 19 vaccination programme because of in the UK work at a higher level of the mass vaccine sites taking over, for intensity than elsewhere in Europe. GPs example, the rate of vaccination in the UK have the shortest consultation slowed—especially in the hardest to times in Europe, and UK GPs tend to see reach groups—and complaints increased
“GPs and their teams have played an essential role throughout the pandemic. GP teams in England alone deal with over 300 million contacts each year” Photo by Charles Deluvio on Unsplash
more than twice the safe recommended GPs per 1000 patients in England, down number of patients per day. from 0.52 in 2015, which, when added to growing demand from the rising BMA appointment data show huge number of people living with complex increases in activity over the past 18 chronic illness and poverty along with an months. Yes, there are more telephone ageing population, means that primary appointments and fewer face to face care is in a desperate situation. GP appointments, but this is the same in all turnover is higher in deprived areas sectors of society—and the same for further exacerbating health inequalities. both community and hospital care. It should come as no surprise, or make Demand on general practice is headline news, because remote working increasing, while at the same time is in line with direct government policy general practices are struggling to and is there to protect both patients and recruit staff. The current deepening GP staff from a highly infectious and crisis that we are facing is having potentially lethal virus. It is especially widespread effects on patient care important to protect the many nationwide. The current crisis long vulnerable individuals we look after in predated covid-19, but the pandemic general practice, in a time when there has highlighted the large cracks in the are over 30,000 covid-19 cases reported NHS. GP teams should not be made daily in the UK. scapegoats for the political failings, under-funding, and shortages of Despite political promises for an essential staff, which are the root cause additional 6000 additional GPs in of the issue. England by 2024, there has been a reduction in numbers rather than an General practice is often described as increase. While there is a clear link the “Bedrock of the NHS,” and the NHS between ratios of family doctors and life Five Year NHS View states that “if expectancy, the number of patients per General Practice Fails the NHS Fails.” We practice is now 22% higher than it was in must be mindful of that, and instead of 2015, and the GP workforce has not blaming GPs for the current crisis, look grown with this demand. As a result, at what can be urgently done to there are now just 0.46 fully qualified alleviate the crisis. Simon Hodes, GP partner in Watford, GP trainer, appraiser and LMC rep. Twitter: @DrSimonHodes Frances Mair, Norie Miller professor of general practice. Twitter: @FrancesMair Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, London, UK, Twitter: @Azeem_Majeed This article was first published in BMJ Opinion. FURTHER READING: Why MPs and journalists need to speak to their local general practices Will the NHS survive without GPs?
Image by rawpixel.com “…the number of patients per practice is now 22% higher than it was in 2015, and the GP workforce has not grown with this demand”
After a 20-year relationship between Dr Foster Ltd and the Imperial College academic research unit led by Professor Paul Aylin and Professor Alex Bottle, funding from Dr Foster Ltd ceased on the 1st September. The relationship started in 2001 with collaboration between Professor Sir Brian Jarman (Emeritus Professor) and the founders of Dr Foster Ltd and resulted in the Good Hospital Guide published in the Sunday Times. This was the first time that data relating to the performance of hospitals was made available in the public domain. It helped to kickstart the move to greater transparency in the NHS and to shape organisations like the Care Quality Commission (and its predecessors). Further work by the Unit led to the joint development of a hospital surveillance tool using routine inpatient data to alert hospital trusts to groups of patients with unexpectedly high or low death and other outcome rates. This system was partially responsible for alerting the CQC’s predecessor organisation to problems at Mid Staffordshire Foundation Trust, and a public inquiry followed. Further work by the Unit drove the move to more consistent care by day of the week, as well as better training for new doctors starting at hospitals. The Unit’s work has been cited in various clinical guidelines and the 2019 NHS Long Term Plan. Much of this research was funded by Dr Foster Ltd, which now has new leadership and direction. The academic unit is now supported by other grants and will continue to carry out pioneering research into the quality and safety of healthcare using big databases.
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CONSENT FOR COVID-19 VACCINATION IN CHILDREN Now that covid-19 vaccination of children in the UK has started, it is essential that the legal basis of consent for a medical intervention in this group are well understood A Court of Appeal ruling on 17 September Now that covid-19 vaccination of children 2021 overturned a previous High Court in the UK has started, it is essential that ruling, and decided that parental consent the legal basis of consent for a medical is not needed for children under 16 to intervention in this group are well take puberty blockers. This reaffirms, understood by parents, carers, health again, that the responsibility to consent to professionals—and most importantly by treatment depends on the ability of children. Teenagers who are aged 16 or 17 medical staff to decide on the capacity of are deemed under English law to be able under 16-year-olds to consent to medical to give their own consent for vaccination. treatment. But what about 12–15-year-olds? The timing is auspicious. Just a few days Ideally, for children who are aged 12-15, before, the four UK Chief Medical Officers covid-19 vaccination would be given with recommended that all healthy children the approval and support of their parents. aged 12-15 should be “offered” a single This is likely to improve children’s covid-19 vaccine, with a booster likely in confidence in covid-19 vaccines and help the Spring 2022. Until now, the only ensure a high and rapid take-up of children in this age group offered a vaccination. With the vaccine programme vaccine have been those with certain due to start in schools before the end of medical conditions, or those living in a September, parents were being sent out household with a clinically vulnerable consent forms, along with NHS adult. With a mass vaccine campaign for information leaflets. Explaining such a children now starting, the issue of consent finely balanced decision in child friendly for vaccines in this group has been terms would be challenging. A survey by headline news. the UK Office for National Statistics reported that around 90% of parents were Reaching the decision about vaccinating in favour of vaccinating children. Surveys 12–15-year-olds in the UK has been an also show good confidence in covid-19 interesting process. The Joint Committee vaccines among children and young adults on Vaccination and Immunisation (JCVI) (but usually at a lower level than among have deliberated, awaiting evolving older people). evidence, and have scrutinised the data available purely on a risk benefit basis for But despite high overall support for covid- the vaccine itself. The chief medical 19 vaccination, there will be families officers looked at wider effects to society, where children and parents may have and given that modelling suggests that very differing opinions about its risks and vaccination of 12–15-year-olds can save benefits. For example, some parents may so many lost days of school, infections be strongly opposed to covid-19 and associated transmission, they vaccination, but their child may have a recommended vaccination to the different view. The opposite situation is government, but leaving the final decision also possible whereby the parents are in to politicians.
favour of vaccination, but the child is scientific evidence suggests. In the court opposed to vaccination. case, the judge (Mr Justice MacDonald) deferred deciding about any future covid- In such circumstances, the NHS and the 19 vaccination because of the “early stage responsible clinicians have to decide if the reached with respect to the covid-19 child is competent to make their own vaccination programme.” However, now decision about covid-19 vaccination. This that vaccination has been approved by is known as ‘Gillick competence’ following the UK government and is supported by a court case in the 1980s between Ms bodies such as Public Health England, it is Victoria Gillick and the NHS about consent highly likely that a court would rule in to treatment for children under 16. The favour of covid-19 vaccination where two court case eventually made its way to the parents had opposing views. House of Lords, which ruled that “As a matter of Law, the parental right to None of these issues are new, and the determine whether or not their minor current HPV vaccination programme has child below the age of sixteen will have tested many of the issues surrounding medical treatment terminates if and when vaccination in this age group already. the child achieves sufficient However, the scale and speed of the understanding and intelligence to covid-19 vaccination may be far more understand fully what is proposed.” The contentious—particularly given the finely ruling is valid in England and Wales. balanced risk-benefit profile, the small risks of myocarditis, and the vaccine Whether a child is Gillick competent is hesitancy already noted in younger assessed using criteria such as the age of people. the child, their understanding of the treatment (both benefits and risks) and It is important that parents, teachers, and their ability to explain their views about healthcare professionals understand the the treatment. If deemed to be Gillick risk and benefits of covid-19 vaccination competent, the child can make their own for children, so that we can support them decision about a medical intervention in reaching an informed decision. We such as covid-19 vaccination. need to respect the ability of our children, whose lives and education have been so There may also be situations in which two greatly affected and disrupted by the parents disagree about covid-19 pandemic, to reach their own conclusions vaccination. If the child is not Gillick given the evidence available. Where there competent, then a decision needs to be is a disagreement between a child and made about which parent’s views take their parents or legal guardians regarding priority. In a court case in 2020 where two any medical treatment, healthcare parents disagreed about vaccination for professionals must feel confident in their children, the Judge ruled that judging Gillick Competence and the issues vaccination was in the best interests of surrounding capacity to give consent. the child because this is what the This article was first published in BMJ Opinion See also: Covid-19 vaccines for teenagers: conversations and consent
VACCINATING HEALTHCARE WORKERS AGAINST COVID-19 In an article published in the British Medical Journal, we discuss the topic of vaccinating healthcare workers against Covid-19. Our conclusion is that compulsion is unnecessary and inappropriate. Parliament’s decision to make vaccination level of staff vaccination for healthcare against covid-19 a condition of settings, but over 80% of frontline employment for care home workers has healthcare workers in NHS trusts have fuelled the debate around compulsory now received two vaccine doses,4 vaccination for healthcare workers, which reaching over 90% in some trusts. The may follow. Compulsory vaccination is not level of risk posed by the remaining a panacea and may harm the safety of minority is unlikely to justify policy change patients and healthcare workers, as well at a national level. as affecting workload and wellbeing. It is a dilemma familiar to occupational health Vaccination is already compulsory for staff services in many NHS trusts. working in healthcare settings in France and Italy. However, both countries have a Is there a vaccine hesitancy problem in UK history of compulsory vaccinations in healthcare for which mandatory response to substantial vaccine hesitancy vaccination is an appropriate solution? and outbreaks of vaccine preventable Data suggesting pockets of poor uptake of infections such as measles. In Italy, covid-19 vaccination among care home legislation introducing compulsory staff led the government to make childhood vaccinations was followed by a vaccination compulsory, abandoning a decrease in the incidence of measles and targeted but voluntary approach. The rubella. Nevertheless, this policy is under government’s Scientific Advisory Group review and may be made more flexible for Emergencies (SAGE) has not published depending on regional vaccine coverage. a recommended minimum acceptable The full text of the article is available in the BMJ. HOW LONG DOES IMMUNITY FROM COVID-19 VACCINATION LAST? In a letter published in the British Medical Journal, Prof Azeem Majeed discusses the topic of how we assess the long-term safety and efficacy of Covid-19 vaccination. Vaccines for COVID-19 were eagerly England, Scotland and Israel show that awaited; and their rapid development, vaccination provides a high level of testing, approval and implementation are protection from symptomatic COVID-19 a tremendous achievement by all: infection and serious illness, along with a scientists, pharmaceutical companies, large reduction in the risk of hospital drugs regulators, politicians and admissions and death. healthcare professionals; and by the patients who have received them.[1] Early However, because these vaccines are real-world data from vaccine recipients in new, we do not yet have information on
how long the immunity generated by its strong life sciences research industry, COVID-19 vaccines will last; or on how to guide public health decision making. well they will protect against new variants We also have a National Health Service of SARS-CoV-2. Longitudinal data on that has developed computerised medical ‘vaccine failures’, or re-infections can help records for use in general practices on a guide national policies on how frequently population of around 67 million people. booster doses of vaccines are needed to These electronic medical records provide maintain a good level of immunity in the longitudinal data on people’s health and population, and on whether vaccines need medical experiences and can be used to modification to provide protection against estimate the longer-term efficacy of new variants of SARS-CoV-2.[2] Covid-19 vaccines.[3] This will provide a valuable resource, not just for guiding The UK is well-placed to collect these data public health policy in the UK, but also for and to secure its timely evaluation and global health. integration with information provided by References 1. Majeed, A, Molokhia, M. Vaccinating the UK against COVID-19. BMJ 2020; 371: m4654–m4654. 2. Majeed A, Papaluca M, Molokhia M. Assessing the long-term safety and efficacy of COVID-19 vaccines. Journal of the Royal Society of Medicine. May 2021. doi:10.1177/01410768211013437 3. Hodes S, Majeed A. Building a sustainable infrastructure for covid-19 vaccinations long term BMJ 2021; 373 :n1578 doi:10.1136/bmj.n1578 WHAT ARE THE ARGUMENTS IN FAVOUR OF REDUCING THE GAP BETWEEN DOSES OF THE PFIZER COVID-19 VACCINE TO 3-4 WEEKS? Early on during the pandemic, the UK government took the decision to give second doses of the Pfizer Covid-19 vaccine after 12 weeks rather than the recommended 3-4 weeks. It has now reduced the gap to 8 weeks and is considering reducing the gap to 3-4 weeks. What are the arguments in favour of reducing the gap between doses to 3-4 weeks? 1. Giving the two doses of the Pfizer vaccine 3-4 weeks apart is in line with the manufacturer’s guidance. 2. This is what most other countries using the Pfizer vaccine are doing. 3. Evidence from randomised controlled trials and subsequent evidence from real-world data provides strong evidence that two doses of Pfizer vaccine given 3-4 weeks apart provide excellent protection against severe disease and death 4. Data from Public Health England shows that two doses of vaccine provide much better protection against the delta variant than one dose. Hence, giving second doses after 3-4 weeks instead of after 8-12 weeks could help reduce the current ratee of infection in the UK 5. Many people are keen to get their second dose of Pfizer vaccine quickly because of concerns about other family members or to help them travel.
Having multiple sclerosis and depression is associated with an increased risk of early death Depression is common in people with multiple sclerosis (MS), and a new study from our research group shows that people with both conditions are more likely to die over the next decade than people with just one or neither condition. The study was published in the September 2021, online issue of Neurology, the medical journal of the American Academy of Neurology. The study also found that people with MS and depression have an increased risk of developing vascular disease such as heart attack and stroke. “These findings underscore the importance of identifying depression in people with MS as well as monitoring for other risk factors for heart disease and stroke,” said lead author Raffaele Palladino, MD, PhD, of PCPH, Imperial College London. “Future studies need to be conducted to look at whether treating depression in people with MS could reduce the risk of vascular disease as well as death over time.” Photo by Foad Roshan on Unsplash
The study involved 12,251 people with MS and 72,572 people who did not have MS. We looked at medical records to see who developed vascular disease or died over a period of 10 years. At the start of the study, 21% of the people with MS had depression and 9% of the people without MS had depression. We found that people with both MS and depression had a mortality rate from any cause of 10.3 per 100,000 person-years. Person-years take into account the number of people in a study as well as the amount of time spent in the study. The mortality rate for people with MS without depression was 10.6, for people who had depression without MS it was 3.6 and for people with neither condition it was 2.5. Once we adjusted for other factors that could affect the risk of death such as smoking and diabetes, we found that people with both conditions were more than five times more likely to die during the next decade than people with neither condition. People with MS without depression were nearly four times more likely to die than people with neither condition and people with depression without MS were nearly twice as likely to die. For the risk of vascular disease, the rate for people with both MS and depression was 2.4 cases per 100,000 person-years; 1.2 for people with MS without depression; 1.3 for people with depression without MS; and 0.7 for people with neither condition. After adjusting for other factors, we found that people with both conditions were more than three times as likely to develop vascular disease as people with neither condition. “When we looked at the risk of death, we found that the joint effect of MS plus depression equaled more than the effect for each individual factor alone — in other words, the two conditions had a synergistic effect,” Palladino said. “A total of 14% of the effect on mortality rate could be attributed to the interaction between these two conditions.” Materials for this article were provided by the American Academy of Neurology.
Children experiencing social disadvantage in their first few years of life have a greatly increased risk of asthma persisting into adulthood. These are the findings of a study, published in the journal Thorax, looking at the early life circumstances of thousands of UK children and their risk for persistent asthma as teenagers. Image by OpenClipart-vectors from Pixabay
Researchers from Imperial College London and the University of Liverpool used data from almost 7,500 children born in the UK between 2000-2002. Comparing the relative impacts of a range of early life circumstances on asthma risk (such as birthweight, parental smoking, quality of housing and neighbourhood), their analysis found that being born into disadvantaged circumstances increased the likelihood of developing persistent asthma by 70%, with almost two-thirds (59%) of the risk attributable to early life exposures; before the children reached three years old. The researchers say their findings circumstances, tend to have a much highlight how social and economic factors higher risk of developing asthma, but they are driving persistent asthma among the also have more asthma attacks, most disadvantaged children in the UK. hospitalisations and are more likely to die They add that while the condition is from asthma,” said Sonia Saxena, manageable, persistent asthma is still Professor of Primary Care within responsible for preventable Imperial’s School of Public Health. hospitalisations and deaths, and that the UK has among the worst death rates for “What this study shows is that social and asthma in Europe. economic disadvantage overwhelmingly takes hold early in life, in the first few “We know that children from poorer years, and has a potential life-long impact backgrounds, who live in disadvantaged on respiratory and general health.” DISADVANTAGE IN EARLY YEARS In the study, the team looked at a cohort of 7,487 children from England, Scotland, Wales and Northern Ireland, born between 2000-2002, taking data at multiple timepoints throughout their lives (at 9 months, and then 3, 5, 7, 11 and 14 years). Children were allocated to six groups, degree qualifications; 2) diploma in higher based on their mother’s level of education; 3) A levels; 4) GCSEs (grades A– education: 1) higher degree or first-
C); 5) GCSEs (grades D–G); 6) None of such as birthweight, whether they were these qualifications. breastfed, family size, and if their parents The researchers explain that maternal smoked, as well as wider environmental educational status is a strong proxy for factors such as housing conditions, social disadvantage, that tends to cluster proximity to main roads, and from an early age. For example, mothers neighbourhood. with the lowest educational attainment are more likely to live in low-income They found that by age 14, the prevalence households, where housing conditions are of persistent asthma in the most poor, overcrowded or damp. Their disadvantaged children was 20%, children are more likely to have passive compared with 13% for the most exposure to cigarette smoke or pollution advantaged. Disadvantaged children were from living in a polluted or high traffic more likely to have a younger mother at neighbourhood where air quality is birth, belong to a minority ethnic group poorest. and live in poorer-quality housing and neighbourhoods (e.g. crowded, poor- By tracking the group from infancy up quality rented accommodation, with no until the age of 14, they compared the access to a garden, in a built-up area, with impact of a range of physical, heavy traffic or poor air quality). socioeconomic and environmental factors, NEW MEASURES NEEDED According to the researchers, the work highlights the toll that health inequalities in early life have on health in adolescence. They argue that public health measures and policies are urgently needed to support families, address early life behaviours (such as parental smoking), and improve housing conditions for families with children. Dr Hanna Creese, a Child Health Unit asthma is coming from the types of Research Associate within PCPH, and first exposures you get when you don't have author of the study, said: “The wider any control over the environment in implication of our work is that if we want which you are raising your child. to prevent disadvantaged children reaching adolescence and adulthood in “If the government is serious about worse health than their peers, we need to ‘levelling up’ the UK, it needs to start right improve conditions during pregnancy and at the beginning of life, to ensure children childhood to support the healthy start on an equal footing.” development of children and reduce inequalities across the life course. This The research was funded by the National means fundamental changes to housing, Institute for Health Research, through the education and social care.” Harnessing Data for Child Health work programme in the NIHR School for Public Professor Saxena added: “Our work Health Research. highlights the biggest impact on childhood ‘Disadvantage in early-life and persistent asthma in adolescents: a UK cohort study’ by Hanna Creese, et al. is published in Thorax. BBC News Coverage - Short Film
Image by OpenClipart-vectors from Pixabay
The Self-Care Academic Research Unit (SCARU) is collaborating with David Skinner (President, International Self-Care Foundation) & Pete Smith (President, Self-Care Forum UK) on a horizon scanning exercise that considers how the world may be like in 2030, and what this means for self-care policy and practice. We currently have a huge variety of self-care technologies at our disposal including over-the-counter medicines, vitamins, minerals, wearables and smartwatches and online/digital health tools and apps. The future will likely be characterised by the pervasive use of artificial intelligence, remote monitoring tools, biosensors & rapid point-of-care test devices. Self-care is the oldest type of care, but its study as an area of serious academic interest was often neglected. This is quickly changing now that individuals, health systems and governments are recognising the value of self-care as the only means to tackle the rising burden of so called “diseases of the lifestyle” such as type 2 diabetes, obesity & cardiovascular disease. The World Health Organization recently published a Guideline on Self-Care Interventions for Health & Wellbeing, and this was a signal moment for governments to consider how best to embed self-care in policy & practice. The horizon scanning exercise will be informed by discussions with a wide mix of health & social care stakeholders including commissioners of health & wellbeing initiatives, physiotherapists, social prescribers, doctors, nurses, pharmacists & local authority staff. What do you think the future will look like, and how do you think this will influence how we self-care? To share your views, please contact Austen El- Osta, David Skinner or Pete Smith.
‘Global champion’ Prof. Mala Rao awarded prestigious Alwyn Smith Prize for outstanding service to public health Her tireless work spanning public health practice, policy and research was recognised in October 2021 with the Faculty of Public Health (FPH) award which recognises her exceptional contribution to improving the public’s health through research. Professor Mala Rao OBE, NIHR ARC NWL influence to raise the awareness of Ethnicity and Health Theme Lead and climate change on health, the importance Senior Clinical Fellow, Imperial College, is of universal access to health care and a well-known and highly regarded public sanitation and most recently highlighted health doctor and co-founder of the NHS the rise of eco anxiety in young people. Race and Health Observatory. Her research and advisory roles cover many Mala said: areas including race equality, workforce “I am deeply honoured, and humbled, to development, strengthening health receive this award from the Faculty, as systems and environmental health. Mala probably the first ethnic minority person is known for high impact research projects to do so, and very much hope others will that inform her prominent sector voice follow me. Public health achievements are and position her as an influential leader impossible without the inspiration, and role model to many. support, friendship and allyship of others. To those, who are reflected in this RELENTLESS COMMITMENT recognition, I say a heartfelt thank you.” Professor Maggie Rae, President FPH said: “Your research on policy issues has AN ‘OUTSTANDING CONTRIBUTION’ influenced health strategies benefitting The Alwyn Smith Prize is a discretionary millions of people in the UK and globally, prize awarded annually \"to the FPH and your commitment to social justice and member or fellow judged to have made race equality has been relentless.” the most outstanding contribution to the She continued: health of the public by either research or practice in community medicine (public LEADING THE CONVERSATION health medicine)”. The prizes acts as a In a highly distinguished career Mala has platform to promote and celebrate the lead research on global health, climate contributions and achievements of change and social equality gaining outstanding individuals. international recognition for her pioneering work. She has used her FULL ARTICLE Prof Rao also recently made the list of near misses for the HSJ ‘50 most influential Black, Asian and minority ethnic people in health’ ‘She is one of the country’s leading public health doctors and has been an influential voice on climate change – particularly its impact on women. She is a Senior Clinical Fellow in the Department of Primary Care and Public Health at Imperial and co-chair of the Race Equality Public Action Group, which is supporting National Institute for Health Research in promoting race equality in health research and scholarship.’
The Undergraduate Primary Care Education Team held its Annual Teachers Conference on 15 September. This was the first time the conference has been held online. The conference was open to everyone who has contributed to teaching our medical students or plans to get involved in teaching and we were pleased to be able to welcome more than 100 delegates from all over the United Kingdom.
We were delighted to have Dr Farzana Hussain (pictured on previous page) as our keynote speaker. Dr Hussain is GP principal at The Project Surgery and Primary Care Network Clinical Director for Newham Central and was named as the Pulse GP of the Year in 2019. She gave an inspiring and insightful talk on the challenges of balancing work with our communities, so we have happier doctors and healthcare staff and happier communities, at a time when the NHS is shifting to becoming a well-being rather than a \"treating sickness\" service and our workforce is stretched. The presentations from our medical inclusive learning environment, students have always proved one of make live online teaching great the highlights of the conference in again, coaching skills, balancing the past and despite the change of clinical and teaching responsibilities, platform, this year was no different. professional identity formation and Shahmeer Mohammad presented graphic medicine. his experiences on the new I- Explore module and student shaper After a break, students from across Kinan Wihba gave his perspective all years of teaching were awarded on ‘Shaping An Inclusive Primary prizes and this was followed by our Care Curriculum’. tutor awards. Many congratulations to Dr Tamara Joffe and Church End Three pairs of Community Action Medical Centre (Practice Award) Project students, winners from each who won Teaching Excellence term, presented their interventions. Awards, Dr Adnan Saad and Dr The delegates were asked to vote Akbar Khan for their Supporting the on which they thought was the best Student Experience Awards and Dr project overall and this was Heather Molyneux who received awarded to Thivyaa Gangatharan the Outstanding Contribution to and Ellen Wrathall for their Teaching Award. intervention aiding parents, carers and GPs in accessing Child Mental We also ran, as every year, a Health Services in Greenwich. photography competition for final year students on their GP The delegates then broke out into placements outside of London. You workshops. This year these took on can see a couple of entries opposite a variety of topics: creating an and overleaf.
RESEARCH FHSC - HIGHLIGHTING THE CHALLENGES OF FAMILIAL HYPERCHOLESTEROLAEMIA New publication in The Lancet on first data from the European Atherosclerosis Society (EAS) Familial Hypercholesterolaemia Studies Collaboration (FHSC) global registry, established in 2015 and led by the Imperial Centre for Cardiovascular Disease Prevention (ICCP), of >42,000 individuals from 56 countries provides a unique snapshot into the worldwide burden and challenges of Familial Hypercholesterolaemia (FH) care. Detection needs to be earlier, with greater use of intensive lipid-lowering therapy, including combination treatment, to attain guideline goals. Treatment of women also lags that of men. FH is an inherited condition that by the World Health Organization affects about 1:300 people, >25 (WHO) Report on FH in 1998, million people worldwide. Without however, progress in implementing effective lipid-lowering treatment, the recommendations to address people with FH are at increased risk these challenges has been limited. of early heart attacks, often in First data from the FHSC provide a middle-age, due to elevated low- baseline for current FH care density lipoprotein cholesterol worldwide”. levels from birth. Early detection is essential to reduce this debilitating Lead author and FHSC Chief burden of disease and to gain Scientist Dr Antonio Vallejo-Vaz of decades of healthy life for people ICCP stated, “As an inherited with FH. condition, FH is diagnosed too late, on average in the mid-40s, meaning FHSC Lead and EAS President Prof that many years elapse before Kausic Ray of ICCP stated, “The patients are identified and challenges of FH were highlighted treatment is started.” LEARN MORE ABOUT THIS REPORT
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