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What will Brexit mean for the NHS?

On the 29 March 2017, the Prime Minister of the UK Theresa May, formally notified the European Union (EU) Council President, Donald Tusk, of the UK’s intention to leave the EU. Theresa May’s letter to Donald Tusk triggers a two-year process during which the UK will have to negotiate both the terms of its exit from EU and the arrangements that will replace those we have had for over 40 years with the other member states of the EU. The consequences of the United Kingdom’s departure from the EU (commonly referred to as ‘Brexit’) will be wide-ranging and will affect all areas of UK’s society, including the National Health Service (NHS).

For the NHS, Brexit comes at a time when it faces many other major challenges. These include severe financial pressures, rising workload, increased waiting times for both primary care and specialist services, and shortages of health professionals in many key areas (such as in general practice and in emergency departments). The NHS also faces challenges fr…

Gender identity and the management of the transgender patient: a guide for non-specialists

A recent article published in the Journal of the Royal Society of Medicine discusses the management of transgender patient. Transgender people, whose gender identities, expressions or behaviours differ from those predicted by their sex assigned at birth, are receiving increased attention both in the general media and in the medical press. Recent guidelines in the UK have proposed placing much of the responsibility of care for transgender patients on primary care physicians and their teams. With waiting lists for most gender identity clinics extending beyond 12 months and increasing numbers of patients coming forward for treatment, hospital doctors are also likely to encounter transgender patients in their clinical practice.

General Medical Council guidance published in 2016 recommended that general practitioners play a key role in the care of transgender patients. This includes counselling or appropriate referral (which can be done directly by general practitioners, without an interi…

National rules are needed about restriction of NHS prescriptions for drugs available over the counter

A recent news article in the BMJreported that many clinical commissioning groups (CCGs) in England are trying to restrict NHS prescriptions for drugs that are also available over the counter (OTC). This would include, for example, drugs such as antihistamines. This raises a number of issues. Firstly, CCGs have no legal power to limit the prescribing of drugs by GPs (although many CCGs and GPs don’t seem to know this). The only drugs that GPs are not allowed to prescribe are those listed in Part XVIIIA of the NHS Drug Tariff (sometimes referred to as the ‘blacklist’). 

Secondly, rather than going through a formal process and asking the Department of Health to place additional drugs on the ‘blacklist’, CCGs seem content to let doctors decide who should have these drugs on NHS prescription and who should not. This will inevitably lead to considerable variation between GPs in their propensity to prescribe these drugs, thereby leading to ‘postcode prescribing’. 

Thirdly, it also raises legal…

Interview with the British Medical Journal

The BMJ published an interview with me in March 2017 for their 'Observations' section.

What was your earliest ambition?
As a boy I was keen to be a pilot. My poor eyesight put an end to that ambition.

Who has been your biggest inspiration?
Two of my former consultants, James Stuart and Keith Cartwright, who mentored me early in my career, helped me write my first scientific papers, and started me on my academic career path.

What was the worst mistake in your career?
Early in my career I admitted a man who had undergone some changes in behaviour after a minor head injury. I did not consider ordering a CT scan immediately, but fortunately my senior registrar did, and a diagnosis of a subdural haematoma was made. The patient underwent surgery that evening and had a good outcome.

What was your best career move?
Moving to London in the 1990s to take up my first academic post. Although I was unsure about moving to such a large city, having always lived in much smaller towns, working in Lond…

Brexit may exacerbate shortages of health professionals in the UK

The UK’s departure from the European Union will have wide ranging consequences, including doctors leaving the country. As a member of the EU for over 40 years, the UK is fully linked with Europe in all sectors of its society. This includes the NHS, which faces major risks if it fails to tackle the challenges that Brexit poses.

The NHS has faced shortages in its clinical workforce for many decades and has relied heavily on doctors, nurses, and other health professionals who were trained overseas to fill the gaps. This reliance will not end in the foreseeable future. Jeremy Hunt, the health secretary for England, has announced that the government will support the creation of an additional 1500 medical student places at England’s medical schools, but these students won’t complete their medical courses and postgraduate medical training for over 10 years.

The recruitment of medical staff trained overseas has been facilitated by EU legislation on the mutual recognition of the training of h…

A woman with a suspected viral rash in pregnancy

My article in the BMJ considers how doctors should approach the management of a woman with a suspected viral rash during pregnancy. Key points in the article include:

Consider country of origin in a woman presenting with a rash in pregnancy and ask for immunisation history.Test for measles and rubella IgM and IgG antibodies, particularly if immunisation history is not clear.Refer women with an active infection to the fetal medicine unit for fetal monitoring.
The full article can be read in the BMJ.

Warning signs might have been missed in one in six heart attack deaths in England

Heart attack symptoms might have been missed in many patients, according to a study on all heart attack hospital admissions and deaths in England from Imperial College London. More research is urgently needed to establish whether it is possible to predict the risk of fatal heart attacks in patients for whom this condition was not recorded as the main reason for hospital admission. The study was published in The Lancet Public Health.

Heart disease is one of the leading killers in the UK. According to the British Heart Foundation, heart attacks lead to one hospital visit every three minutes. They are caused by a decrease in blood flow to the heart, usually as a result of coronary heart disease. Symptoms may include sudden chest pain or a 'crushing' sensation that might spread down either arm. Patients might also experience nausea or shortness of breath. However, some heart attacks have more subtle symptoms and may therefore be missed or overlooked.

In this study, we examined re…

A carer proposes covertly medicating a patient - what should I do?

You are called by a worker at a care home. She is concerned about a dementia patient who, despite all non-drug measures being tried, is causing distress to other residents. She asks you to prescribe a sedative to ‘slip into her food’. How should you proceed?

Giving medication covertly to sedate an agitated patient raises serious legal and ethical issues. Treatment without consent is only permissible where there is a legal basis for this. In the scenario described here, giving a sedative to the patient without her knowledge and consent would be a breach of her human rights. There is also a risk that the patient could suffer side effects from the medication she was given. For example, administration of a benzodiazepine or an antipsychotic drug could lead to a fall or a fracture that resulted in serious harm to the patient. Covert administration of medication is also a breach of trust on the part of the doctor who prescribed the medication. Hence, it may lead to a formal complaint agains…

Use of interrupted time series analysis in health services research

Although randomized control trials (RCTs) are the ‘gold standard’ to evaluate treatment effects in health care, they are frequently not practical, ethical or politically acceptable in the evaluation of many health system or public health interventions. In the absence of an RCT, evaluations often use quasi-experimental designs such as a pre-post study design with measurements before and after the intervention period, such as interupted time series (ITS). An ITS compares the intercept and slope of the regression line before the intervention with the intercept and slope after intervention. A one-time baseline effect of the intervention without influencing the secular trend can be detected as an intercept change. If the intervention changed the secular trend, there will also be a significant difference in the slope between the two periods. Use of ITS in biomedical research is described in more detail in an article published by Utz Pape and colleagues in the Journal of the Royal Society of…

Improving discharge planning in NHS hospitals

Factors that need to be considered in discharge planning that have been identified in previous projects include:

Ensuring that discharge arrangements are discussed with patients, family members and carers; and that they are given a copy of the discharge summary.Adequate coordination between the hospital, community health services, general practices, and the providers of social care services.There is a follow-up after discharge of patients at high risk of complications or readmission - either in person or by telephone - to ensure that the discharge arrangements are working well. Medicines reconciliation is carried out. This is the process of verifying patient medication lists at a point-of-care transition, such as hospital discharge, to identify which medications have been added, discontinued, or changed from pre-admission medication lists.Ensuring that any outstanding test results at discharge are obtained and passed on to primary care teams; and ensuring there are clear arrangements …

Preparing for the impact of Brexit on health in the UK

The consequences of the United Kingdom’s departure from the European Union (EU) will be wide-ranging. As a member of the EU for over 40 years, the UK is fully linked with Europe in all sectors of its society. This includes the UK’s life sciences sector, which faces major risks if it fails to address the challenges that Brexit poses. The UK’s life sciences sector includes the National Health Service (NHS), the UK’s universities and medical schools, the pharmaceutical sector, and the medical devices industry. With over one million employees, and an annual spend of over £100 billion, the NHS is England’s largest employer. For many decades, the NHS has faced shortages in its clinical workforce and has relied heavily on overseas trained doctors, nurses and other health professionals to fill these gaps. This reliance on overseas-trained staff will not end in the foreseeable future. For example, although the Secretary of State for Health, Jeremy Hunt, has announced that the government will …

Improving the safety of care of people with dementia in the community

Dementia care is predominantly provided by carers in home settings. We aimed to identify the priorities for homecare safety of people with dementia according to dementia health and social care professionals using a novel priority-setting method. The study was published in BMC Geriatrics.

The project steering group determined the scope, the context and the criteria for prioritization. We then invited 185 North-West London clinicians via an open-ended questionnaire to identify three main problems and solutions relating to homecare safety of people with dementia. 76 clinicians submitted their suggestions which were thematically synthesized into a composite list of 27 distinct problems and 30 solutions. A group of 49 clinicians arbitrarily selected from the initial cohort ranked the composite list of suggestions using predetermined criteria.

Inadequate education of carers of people with dementia (both family and professional) is seen as a key problem that needs addressing in addition to …

Can GPs refuse to treat dental abscesses?

I was asked by the professional magazine Pulse to discuss the question of whether GPs can refuse to treat dental abscesses.
A study published in 2016 reported that around 600,000 consultations annually with GPs are for dental problems. Reasons why people present to GPs with dental problems include the poor provision of NHS dental services in many parts of England and the £19.70 charge that some patients must pay for a dental consultation. If you decide that your patient may have a dental abscess, assuming there are no red flags (such as signs of spreading infection or sepsis) that would warrant an urgent referral for emergency hospital assessment, then the patient should be informed that they need to see a dentist. You should explain to the patient that a dentist is trained to treat dental abscesses but you are not. The dentist has the expertise and equipment needed to assess the patient, carry out suitable investigations (such as dental radiographs), and drain the abscess if this is…