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Showing posts from 2017

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…

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 experience…

Community Outreach in West London

Members of the School of Public Health held a very productive and informative meeting today 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 programm…

Research using primary care databases in the United Kingdom

Data collected in electronic medical records for a patient in primary care can span from birth to death and can have enormous benefits in improving health care and public health, and for research. Several systems exist in the United Kingdom (UK) to facilitate the use of research data generated from consultations between primary care professionals and their patients.

In a study published in the Journal of Innovation in Health Informatics, we carried out a bibliometric review to analyse the research outputs and the longitudinal growth in the number of publications that harness the three main UK primary care databases: CPRD, QResearch and THIN.

These databases collectively produced 1,296 publications over a ten-year period, with CPRD producing 63.6% (n=825 papers), THIN 30.4% (n=394) and QResearch 5.9% (n=77). Pharmacoepidemiology and General Medicine were the most common specialities featured.

The growth in publications from these databases shows that they are making an important contr…

Improving how secondary care and general practice in England work together: the NHS Standard Contract

Due to the increasing pressures on general practices within the National Health Service in England, the interface between primary and secondary care, and the division of labour between these, has become an important issue. This has long been an area prone to difficulties and conflict, the consequences of which can directly impact the quality and safety of patient care, particularly for patients with chronic conditions who regularly transition between these two sectors. In an article published in the Journal of the Royal Society of Medicine, Amy Price and I explore the measures recently implemented in the NHS Standard Contract which aim to target common issues at the primary–secondary care interface, with an aim to reducing inappropriate general practitioner workload in England. We discuss the context behind the implementation of the NHS Standard Contract as well as current concerns and areas for further consideration.

The current crisis in primary care means the NHS Standard Contract…

Routes to the diagnosis of heart failure in primary care

Timely diagnosis and management of heart failure (HF) is critical, but identification of patients with suspected HF can be challenging, especially in primary care where patients can present with a range of symptoms of varying severity. In a paper published in the journal Heart, we describe the journey of people with HF in primary care from presentation through to diagnosis and initial management.

We used the Clinical Practice Research Datalink (primary care consultations linked to hospital admissions data and national death registrations for patients registered with participating primary care practices in England) to describe investigation and referral pathways followed by patients from first presentation with relevant symptoms to HF diagnosis, particularly alignment with recommendations of the National Institute for Health and Care Excellence guideline for HF diagnosis.

36 748 patients had a diagnosis of HF recorded that met the inclusion criteria between 1 January 2010 and 31 March…

The child transgender patient in primary care: practical advice for a 10-minute consultation

Children and adults with gender identity concerns are increasingly presenting for treatment, with referrals to specialist clinics rapidly rising. The percentage of children with gender identity disorder that self-harm or attempt suicide is estimated at 50%, so it is essential that it is recognised early and managed appropriately.

Gender identity disorder of childhood usually manifests before puberty. The child typically experiences distress resulting from an incongruence between their current gender identity (sense of themselves as ‘male’, ‘female’, or otherwise), and their gender assigned at birth. Behaviour and activities of the child may stereotypically be associated with that of the opposite gender and the child may be preoccupied with wanting to change their name and gender pronoun (‘she’, ‘he’). Depending on the age, they may also have a strong desire to acquire secondary sexual characteristics of the opposite gender. This may cause significant distress and can impact their per…

Real World Data and Pharmacoepidemiology in Europe

I was in Vienna on Monday 9 October 2017 for the Annual Meeting of the European Epidemiological Forum, which this year is on the topic of “Real World Data and Pharmacoepidemiology in Europe". It’s been a good opportunity to catch up on biomedical research using ‘Big Data’. There is a lot of work going on in this field that will have a big impact on health. There was also some sadness among European colleagues about Brexit and uncertainty about the future role academics and companies from the UK will play in European research collaborations. At the meeting, I was asked to give one of the keynote presentations on the topic of Brexit and how it might affect the UK contribution to research on areas such as pharmacoepidemiology. In my talk, I outlined some of the current uncertainties for UK researchers and the what the future might look like for the UK’s universities, NHS and life sciences sector, depending on the type of Brexit we negotiate with the other countries of the European …

Meeting with Professor Jonathan Weber, Dean of the Faculty of Medicine

We were very pleased to host the Dean of the Faculty of Medicine, Professor Jonathan Weber, in the Department of Primary Care and Public Health on Wednesday 4 October 2017. Professor Weber met with some of the academic staff in the department to learn more about our research and teaching programmes. We had a good discussion about the more ‘social’ and community-based aspects of our work; such as our collaborations with the NHS, local government and voluntary organisations in the White City area of West London; and our work with medical students on areas such as health coaching and behavioural change. We also discussed how our academic work could support Imperial College’s plans for its Imperial West Campus, and creating opportunities for medical students to get involved in community-based research.

Development of a questionnaire to evaluate patients’ awareness of cardiovascular disease risk in England’s NHS Health Check Programme

Cardiovascular disease (CVD) is a major cause of disability and premature mortality worldwide. In England, it accounts for a third of deaths and costs the National Health Service (NHS) and the UK economy £30 billion annually.

The National Health Service (NHS) Health Check is a CVD risk assessment and management programme in England aiming to increase CVD risk awareness among people at increased risk of CVD. There was previously no tool to assess the effectiveness of the programme in communicating CVD risk to patients. In research published in the journal BMJ Open, we describe how we developed a questionnaire examining patients’ CVD risk awareness for use in health service research evaluations of the NHS Health Check programme.

We developed an 85-item questionnaire to determine patients’ views of their risk of CVD. The questionnaire was based on a review of the relevant literature. After review by an expert panel and focus group discussion, 22 items were dropped and 2 new items were a…

Dr Demis Hassabis, Co-Founder and CEO of DeepMind, Speaks about AI in Healthcare

On 28 September 2017, I attended the Annual Institute of Global Health Innovation Lecture: Artificial General Intelligence and Healthcare, delivered by Dr Demis Hassabis, co-founder and CEO of Google DeepMind. Artificial intelligence is the science of making machines smart argued Dr Hassabis, so how can we make it improve the healthcare sector? Dr Hassabis then went on to describe the work that DeepMind was carrying out in healthcare in areas such as organising information, deep learning to support the reporting of medical images (such as scans and pathology slides), and biomedical science. Dr Hassabis also discussed the challenges of applying techniques such as reinforcement learning in healthcare. He concluded that artificial intelligence has great scope for improving healthcare; for example, by prioritising the tasks that clinicians had to carry out and by providing decision support aids for both patients and doctors. Dr Hassabis also discussed some of the ethical issues in using …

Lambeth CCG 2017 Award for Outstanding Contribution to Primary Care

I was very honoured to have won the 2017 Lambeth CCG Award for Outstanding Contribution to Primary Care. Lambeth CCG noted that "Dr Majeed has made a huge contribution to primary care research knowledge as well as provide high quality, kind care to his patients. Dr Majeed was also recognised recently in Pulse magazine as one of the 50 most influential GPs in the UK."

We need activity-based funding and a more tightly defined contract for NHS general practices

In a letter published in the British Medical Journal, I respond to comments from Dr David Shepherd and Dr Hendrik Beerstecher about an editorial I wrote on shortages of general practitioners in the NHS. Dr Shepherd argues that capitation-based funding for general practice can work if the total amount of funding was increase and better methods were used to allocate funds to general practices. Dr Beerstecher argues that there is a mismatch between the supply of general practitioners and demand for their services.

In my response, I state that that increasing the amount of funding for primary care would be a step forward. Moving from the current Carr-Hill formula for allocating budgets to general practices to a formula with more patient level clinical data would also be helpful. But case mix adjusted formulas such as the Johns Hopkins adjusted clinical groups (ACG) system have limitations—particularly when used for smaller populations such as those covered by the typical NHS general prac…

Video consultations can improve both access to GPs and patient experience

The NHS should make better use of video consultations because they can boost patient access and save time and money for both patients and doctors, concludes preliminary research presented at this year’s International Forum on Quality & Safety in Healthcare in Kuala Lumpur (24-26 August).

Current challenges in the UK medical workforce are well known, making accessing a GP in a timely manner difficult, say the researchers (including myself) from Chelsea and Westminster Hospital NHS Foundation Trust and the Department of Primary Care and Public Health at Imperial College London.

The estimated total number of consultations in England rose from 224.5 million in 1995-6 to 303.9 million in 2008-9, with an average wait for a GP appointment of two weeks in some parts of the country. In light of these difficulties, weset up a trial video consultation clinic in two busy London general practices, with lists of nearly 10,000 patients.

Twice weekly video clinics were set up for 23 months to ga…

Global deaths, prevalence and disability for chronic obstructive pulmonary disease and asthma

A recent paper from the Global Burden of Disease (GBD) Chronic Respiratory Disease Collaborators examined the burden of ill-health caused by chronic obstructive pulmonary disease (COPD) and asthma. The paper was published in the journal The Lancet Respiratory Medicine.

COPD and asthma are common diseases with a heterogeneous distribution worldwide. In the paper, we presented findings for COPD and asthma from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2015 study. The GBD study provides annual updates on estimates of deaths, prevalence, and disability for over 300 diseases and injuries, for 188 countries from 1990 to the most recent year.

We found that in 2015, 3.2 million people died from COPD worldwide, an increase of 11·6% compared with 1990. There was a decrease in age-standardised death rate of 41·9% but this was counteracted by population growth and ageing of the global population. From 1990 to 2015, the prevalence of COPD increased by 44%, whereas age-standa…

Does the use of point-of-care testing improve the cost-effectiveness of the NHS Health Check programme?

A paper published in the journal BMJ Open examines if the use of point of care testing is less costly than laboratory testing to the National Health Service (NHS) in delivering the NHS Health Check programme in primary. To address this question, we carried out an observational study, supplemented by a mathematical model with a micro-costing approach.

We collected data on cost, volume and type of pathology services performed at seven general practices using point of care testing and a pathology services laboratory. We collected data on response to the NHS Health Check invitation letter and DNA rates from two general practices.

We found that the costs of using point of care testing to deliver a routine NHS Health Check is lower than the laboratory-led pathway; with savings of £29 per 100 invited patients up the point of cardiovascular disease risk score presentation. Use of point of care testing can deliver NHS Health Check in one sitting, whereas the laboratory pathway offers patients…

Gender differences in hospital admissions for cardiovascular events and procedures in people with and without diabetes

An article published in the journal Cardiovascular Diabetology examines gender differences in hospital admissions for major cardiovascular events and procedures in people with and without diabetes.

Secondary prevention of cardiovascular disease (CVD) has improved immensely during the past few decades but controversies persist about the cardiovascular benefits among women with diabetes. We investigated 11-year trends in hospital admission rates for acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in people with and without diabetes by gender in England.

We found that diabetes-related admission rates remained unchanged for AMI, increased for stroke by 2% and for PCI by 3%; and declined for CABG by 3% annually. Trends did not differ significantly by diabetes status. Women with diabetes had significantly lower rates of AMI and stroke compared with men with diabetes. However, gender differences in admission rates f…

The diagnosis and management of Scarlet Fever in primary care

An article published in the London Journal of Primary Care discusses the diagnosis and management of Scarlet Fever. There has been a recent increase in the incidence of scarlet fever with most cases presenting in General Practice and Emergency Departments. Cases present with a distinctive macro-papular rash, usually in children. In patients who have the typical symptoms, a prescription of a suitable antibiotic such as phenoxymethylpenicillin (Penicillin V) should be made immediately to reduce the risk of complications and the spread of infection.

A typical presentation of scarlet fever
An 8-year-old girl is brought to see you at your practice. She has a sore throat, abdominal pain and has been vomiting. Her health was fine until two days ago. Initially, she noticed pain on swallowing and had a temperature of 38 °C. Her parents decided to seem medical advice once they noticed the ‘sandpaper-like’ rash on her trunk and the inside of her elbows. When you examine her tongue, the enlarged …

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

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

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

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

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

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

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

Diabetes mellitus and chronic kidney disease in the Eastern Med…

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

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

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

Imperial College joins the UK's effort to tackle global health challenges

The Department of Primary Care and Public Health at Imperial College London has been awarded funding as part of a UK drive to tackle global health challenges. The work is funded by Research Councils UK as part of the Global Challenges Research Fund (GCRF), a £1.5 billion fund launched by the UK government in 2015. The fund aims to support cutting-edge research which addresses the global issues faced by developing countries in areas including agriculture, medicine, well-being and infrastructure.

The GCRF funding will also enable Imperial Professors Azeem Majeed, Toby Prevost and Mala Rao to investigate low cost technologies for screening for diabetic eye disease, a leading cause of blindness in India, in partnership with clinicians from Moorfield’s Eye Hospital in London. Professor Mala Rao, who is leading Imperial’s contribution to the project, said: “This award offers a very exciting opportunity for us to work together to transform the lives of people with diabetes and diabetic eye …

Advice on the management of the transgender patient in primary care

A recent article in the journal BJGP Open provides advice on the management of transgender patients in primary care. With referrals to gender identity clinics rising rapidly, general practitioners (GPs) and primary care physicians are more likely to meet patients who are transgender (whose gender identity, or internal sense of gender, does not match their gender assigned at birth) or diagnosed with gender dysphoria (the severe psychological distress that is experienced by an individual as a result of the conflict between their gender identity and gender assigned at birth).1 Teaching on transgender medicine is lacking in both undergraduate and postgraduate curricula, leading to a perceived lack of expertise in this area. Furthermore, General Medical Council (GMC) guidelines on the GP’s role in prescribing are vague, resulting in some controversy. As waiting times for appointments at specialist clinics are often at least 18 months, GPs and primary care physicians will increasingly be i…

Visit to DeepMind

I was invited Google’s headquarters in London today to discuss the work in healthcare being carried out by DeepMind. We had a very interesting discussion about the scope for the use of artificial intelligence in healthcare to improve clinical outcomes and population health. We also discussed the use of predictive modelling to identify patients with long-term conditions at high risk of death, readmissions and complications.

Prioritizing medication safety in care of people with cancer

A recent study from Imperial College London published in the Journal of Global Health examined clinicians’ views on main problems and solutions in medication safety in the care of people with cancer. The top ranked problems focused on patients' poor understanding of treatments due to language or education difficulties, clinicians' insufficient attention to patients' psychological distress, and inadequate information sharing among health care providers. The top ranked solutions were provision of guidance to patients and their carers on what to do when unwell, pre–chemotherapy work–up for all patients and better staff training.

Why I became a mental health champion at Imperial College London

As a doctor with many years experience of working in the NHS, I am aware of the impact that mental health problems can have on people’s health, well-being and quality of life, as well as on their family and friends. Mental health problems are also important for employers, and result in considerable financial costs in lost production and in staff absences from the work-place due to ill-health. However, even though mental health problems are very common, many people find it difficult to talk about them.

Encouraging a supportive environment in the workplace that reduces the risk of mental health problems developing – and in supporting staff to seek help when mental health problems do arise – is very important for employers. It improves employees’ health and well-being, and creates a more productive and pleasant working environment.

As a Mental Health Champion, I see my role as supporting my departmental colleagues to achieve these objectives and ensure that mental health issues in the w…

Shortage of general practitioners in the NHS

In an article published in the British Medical Journal, I discuss the implications of the current shortage of NHS general practitioners. Ensuring that countries have sufficient primary care doctors is a key challenge for health planners globally because of the important role that primary care plays in supporting cost-effective health systems that promote equity in health outcomes. For example, the USA is predicted to need 7,800 to 32,000 additional primary care physicians by 2025.[1] We also know that the National Health Service (NHS) in the United Kingdom is short of general practitioners.[2] What we do not know is the size of the shortage; and how many additional general practitioners the NHS needs to provide comprehensive primary care services.

In its plan for general practice published in 2016, NHS England set a target of 5,000 additional general practitioners by 2020.[3] However, no data was presented to show that this was a sufficient number to meet the needs of primary care in…

Key priority areas for patient safety improvement strategy in Libya

A paper published in the journal BMJ Open describes a protocol for a study examining patient safety in Libya. Patient safety is a global public health problem. Estimates and size of the problem of patient safety in low-income and developing countries are scarce. A systems approach is needed for ensuring that patients are protected from harm while receiving care. The primary objective of this study will be to use a consensus-based approach to identify the key priority areas for patient safety improvement in Libya as a developing country.using a modified Delphi approach.

A three-phase modified Delphi study will be conducted using an anonymous web-based questionnaires. 15 international experts in the field of patient safety will be recruited to prioritise areas of patient safety that are vital to developing countries such as Libya. The participants will be given the opportunity to rank a list of elements on five criteria. The participants will also be asked to list five barriers that th…

The divergence of minimum unit pricing policy across the UK

A paper published in the Journal of the Royal Society of Medicine discusses the implementation of a minimum unit pricing policy across the UK. Above recommended levels of intake, alcohol use is associated with harm including hypertension, haemorrhagic stroke, liver disease, mental health disorders and cancers, as well as accidents, injuries and assaults. The 2015 UK Global Burden of Disease study indicates that 2.9% of disability-adjusted life years and 1.9% of mortality are attributable to alcohol use, and the 2013 Health Survey for England found that 23% of men and 16% of women in England drink at levels associated with risk to health. Despite the ongoing discussion about minimum unit pricing policy across the UK, and although it is difficult to predict what it would take for the Westminster Government to revert to a minimum unit pricing policy, any minimum unit pricing policy that does come to be implemented in Scotland or England and Wales will only be implemented because the rel…

Evaluation of the NHS Health Check Programme in reaching under-served groups

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

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

Between January 2008 and October 2013, community outreach providers delivered a preventive CVD programme to 50,573 individuals, in their local communities, in a single consultation without prescheduled appo…

Health Effects of Overweight and Obesity in 195 Countries

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

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

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

Among the 20 most populous countries, the highest level of obesity among children and young adults was in the Unite…

Sophie the very helpful dragon

A story for five-year olds

Written by Professor Azeem Majeed

Sophie the dragon was sad. Why was Sophie sad? Because the children in the nearby village wouldn’t play with her. Each time Sophie approached the children, they would run away screaming. She often asked her mother why the children would not play with her.

“It’s because the people of the village are afraid of dragons.” Her mother said. “The village chief, Donald, has told the villagers that dragons are terrible creatures; that we will burn down their houses, eat their farm animals, and carry off their children.”

“That’s a horrible thing to say.” Said Sophie. “We dragons are kind and gentle, and want to help others”.

“True.” Said Sophie’s mother. “But Donald is their chief and the other villagers believe what he says.”

One day, Sophie could see the villagers collecting wood and placing it into a big pile in the middle of the village green.

“What are they doing?” Sophie asked her mother. “It will be bonfire night soon.” Replied …

Current and future perspectives on the management of polypharmacy

A paper published in the journal BMC Family Practice discusses the management of polypharmacy (the concurrent use of multiple medications by one individual). Because of ageing populations, the growth in the number of people with multi-morbidity and greater compliance with disease-specific guidelines, polypharmacy is becoming increasingly common.

Although the correct drug treatment in patients with complex medical problems can improve clinical outcomes, quality of life and life expectancy, polypharmacy is also associated with an increased risk of adverse drug events, some severe enough to result in hospital admission and even death. Hence, having systems in place to ensure that medications are started only when there is a suitable indication, ensuring patients are fully aware of the benefits and complications that may arise from their treatment, and reviewing patients regularly to ensure their medication regime remains appropriate, are essential.

The development and rapid uptake of el…