National Health Service General Practitioners Research Articles

Impact of the disruption in supply of varenicline since 2021 on smoking cessation in England: A population study.

Varenicline is one of the most effective smoking cessation treatments. Its supply in England was disrupted in July 2021 due to nitrosamine impurities found by its supplier, Pfizer. This study measured the impact of this disruption on smoking cessation in England. The study used repeated cross-sectional surveys conducted monthly, from June 2018 to December 2022. Set in England, it comprised a total of 3024 adults who reported smoking during the past year and had made at least one serious attempt to quit in the past 6months. Generalized additive models analyzed the association of the varenicline supply disruption with the trend in self-reported varenicline use in the most recent quit attempt. We used these results to estimate the population-level impact of the disruption on smoking cessation. Before July 2021, the proportion of past 6-month quit attempts using varenicline was stable at approximately 3.9% [risk ratio (RR)trend = 1.034, 95% confidence interval (CI) = 0.823-1.298]. The trend in varenicline use has changed sharply since the supply disruption (RRΔtrend = 0.297, 95% CI = 0.120-0.738), with prevalence falling by 69.3% per year since; from 4.1% in June 2021 to 0.8% in December 2022. Convergently, National Health Service general practitioner prescribing data reported that just 0.1% of prescriptions for smoking cessation treatments in December 2022 were for varenicline. Assuming that varenicline does not return to the market, we estimate that this could result in ~8400 fewer people stopping smoking for at least 6months, ~4200 fewer long-term ex-smokers and ~1890 more avoidable deaths each year. In England, the disruption in supply of varenicline since 2021 has coincided with a substantial fall in the use of varenicline in attempts to quit smoking.

Estimating Population Counts with Capture-Recapture Models in the Context of Erroneous Records in Linked Administrative Data

In the absence of a traditional census and a comprehensive population register (as it is thecase in the UK), administrative data sources, i.e. health, school or tax records, can offer analternative to estimate the size of residence population. However, such data sources are designedto capture information only from specific populations which imposes a challenge to theestimation. A suitable method to overcome the challenge is to link administrative data sourcesthat collect information from different but overlapping populations and use capture-recapturemodels to estimate the population counts. There are various assumptions required to obtainunbiased estimates by using capture-recapture models. In practice, especially the assumptionson ‘homogeneous inclusion probabilities’ and ‘no over coverage’ are often not met. This paperproposes a two-step procedure for estimating population counts with capture-recapture modelsthat account for heterogeneity of inclusion probabilities and the over coverage in the datasources. We apply our methodology to the linked Patient Register and Customer InformationSystem dataset which violates both of the aforementioned assumptions. The Patient Registerincludes people who are registered with a National Health Service General Practitioner doctor.In 2011, the Patient Register overestimated the size of England and Wales populationby 4.3% (over coverage) and its sex ratio was different than the 2011 Census estimates (heterogeneousof inclusion probabilities). The Customer Information System dataset providesinformation on all individuals who have ever had a national insurance number and childrenwhose parents have made a child benefit claim relating to them. In 2011, it over estimatedthe size of England and Wales population by 9.5% and its age and sex structure was differentthan the 2011 Census estimates. Applying our approach, we estimate population counts ofthe South East region of England by age, sex and local authority, and compare them withcensus estimates using percentage difference maps.

Effect of antibiotics in preventing hospitalizations from respiratory tract infections in children with Down syndrome.

Children with Down syndrome (DS) are at high risk of respiratory tract infections (RTIs) due to anatomical variations, comorbidities, and immune system immaturity. Evidence on interventions to reduce this risk is incomplete. This study aims to quantify the effect of antibiotics prescribed for RTIs in primary care on the subsequent risk of RTI-related hospitalization for children with DS versus controls. We conducted a retrospective cohort study of 992 children with DS and 4874 controls managed by UK National Health Service General Practitioners (GPs) and hospitals as identified in CALIBER (Clinical disease research using LInked Bespoke studies and Electronic health Records), 1997-2010. Univariate and multivariate logistic regression were undertaken. In children with DS, the prescription of antibiotics following an RTI-related GP consultation did not significantly reduce the risk of RTI-related hospitalization in the subsequent 28 days (risk with antibiotics, 1.8%; without, 2.5%; risk ratio, 0.699; 95% confidence interval, 0.471-1.036). Subgroup analyses showed a risk reduction only in infants with DS, after adjustment for covariates. There was no reduction in risk for controls, overall or across subgroups. In conclusion, while prescription of antibiotics following RTI-related GP consultations were effective for infants with DS in reducing subsequent RTI-related hospitalization, this was not the case for older children with DS. We would encourage further high-quality cohort and randomized controlled trials to interrogate this finding, and to examine the impact of antibiotics on other endpoints, including symptom duration.

Developing the libraries and health partnership

Developing the libraries and health partnership

A proposal for the annual appraisal of, and developmental support for, General Practitioners with a Specialist Interest (GPwSIs) in respiratory medicine

This paper provides best practice recommendations for the appraisal of, and developmental support for, GPwSIs in respiratory medicine. These recommendations are closely linked with the current system for quality-assured National Health Service (NHS) general practice appraisal in the United Kingdom (UK). The recommendations are based on Department of Health guidance, and follow consultation with a range of relevant professional bodies involved in respiratory care and professional development. We describe the Primary Care Organisation (PCO) responsibilities, training issues, support systems, and documentation required to ensure that appraisal for GPwSIs in respiratory medicine meets national standards. In addition we address links to NHS general practitioner (GP) appraisal, revalidation, and documentation from the General Medical Council (GMC) on good medical practice. Developmental support that will complement and be sensitive to the needs of the GPwSI in respiratory medicine is described, as well as the ideal situation for educational support for practitioners, and the need for variability of appraisal dependent upon the GPwSI's experience. This appraisal and support system will allow general practice, NHS managers and the public to have confidence that those GPwSIs working in respiratory medicine will provide high quality care.

Pooled cataract waiting lists: views of hospital consultants, general practitioners and patients.

In the National Health Service general practitioners (GPs) usually refer patients to named consultants; thus, waiting times for a particular procedure can vary greatly even within a single centre. An alternative is to pool the waiting list, with patients treated in turn by the consultant available. We sought opinions on this strategy, from patients, GPs, and consultants, in relation to cataract surgery. Questionnaires were sent to 776 consultant ophthalmologists; telephone interviews were conducted with 50 randomly selected Birmingham GPs; and 85 Birmingham patients listed for cataract surgery were asked whether they would change consultant to be operated on sooner. 503 (64%) of the consultants responded. Of consultants, 30% favoured pooled lists and 67% were against. Of patients, 82% favoured pooled lists and 18% were against. Of GPs, 92% favoured pooled lists and 8% were against. Some consultants thought that pooled lists were suitable for routine cases but not for more complex cases. 82% of patients expressed willingness to change consultant in order to get an earlier operation. In units with surgeons whose cataract-surgery practices are similar, pooled lists are one way to maximize theatre use and equalize waiting times for routine cases. The model could be applied to other routine surgical procedures such as hip replacement, herniorrhaphy and prostatectomy.

Violence against doctors: a medical(ised) problem? The case of National Health Service general practitioners

AbstractViolence against doctors provides an illuminating context for studying medicalisation and its limits in the management of deviance. The paper examines the emergence of such violence as a policy issue in England, with particular reference to general practitioners (GPs) in the National Health Service. Recent guidance exhorts doctors to exercise ‘zero tolerance’ with respect to acts of violence. The emphasis is on risk management and protecting victims rather than on resolving the perpetrators’ problems. The paper argues that this policy frame is consistent with recent claims from criminologists that there is a new ‘turn’ in penal policy, away from rehabilitation and addressing the needs of individual offenders. However, responses of individual GPs, obtained through a postal questionnaire sent to c.1000 GPs and in‐depth interviews with a sub‐sample, suggest that doctors are not ‘zero tolerant’ in responding to attacks. But nor are they medical imperialists seeking to include all perpetrators within their professional jurisdiction. Rather, they exercise professional discretion about behaviours which often fall into a ‘grey area’ between ‘illness’ and ‘crime’, and about individuals who are not clearly categorisable as either ‘sick’or‘bad’.

The long-term prognostic significance of repeated blood pressure measurements in the elderly: SPAA (Studio sulla Pressione Arteriosa nell'Anziano) 10-year follow-up.

In young and middle-aged people, both systolic (SBP) and diastolic (DBP) blood pressure have a continuous, strong, and independent relationship with subsequent cardiovascular morbidity and mortality. These relationships are not well documented in older people and, until now, studies in the elderly do not provide homogeneous results on the importance of DBP compared with SBP as a cardiovascular risk factor. To determine whether SBP and DBP are independent indicators of mortality risk in the elderly. An observational prospective cohort study to analyze the long-term prognostic significance of repeated SBP and DBP measurements in the elderly. A total of 3858 outpatients 65 years or older (mean age [SD], 72.9 [4.9] years, 43.5% men) were selected randomly by 444 Italian National Health Service general practitioners in 1983. The population was followed up for 10 years. Crude and adjusted incidence rates of total and cardiovascular mortality were analyzed for classes of SBP and DBP based on the values recorded at the 2 initial visits 1 week apart and those measured during the first 12 months of follow-up. During the 10-year follow-up, 74 patients (1.9%) were lost to follow-up and 1561 (41.3%) died, 709 (45.4% of all deaths) from cardiovascular causes. A positive continuous, graded, strong, and independent association was observed with both total (P<.001) and cardiovascular (P<.001) mortality for SBP but not for DBP. The pattern was similar in both sexes, in persons younger and older than 75 years, regardless of preexisting cardiovascular diseases, and whether they had been receiving antihypertensive treatment at baseline. There was no J-shaped mortality curve in the subjects with the lowest SBP and DBP. These findings suggest that SBP, but not DBP, is a strong, positive, continuous, independent indicator of mortality risk in the elderly and should be stressed much more than DBP in the diagnosis and treatment of hypertension in this age group.

Dermatological surgery in general practice: Management of malignant skin tumours

The number and type of malignant skin tumours excised by general practitioners in South West Hertfordshire was studied to assess the correlation between clinical and histological diagnosis, adequacy of excision, management and follow-up of patients with these lesions. Copy histopathology reports from specimens sent by general practitioners were analysed. Three 12-month periods were studied, two before and one after the introduction of the new UK National Health Service general practitioners' contract. The general practitioners of the patients with malignant tumours excised in the 12-month post-contract period were contacted to establish how the patients had been managed. The study confirmed the rising trend in skin surgery performed by general practioners. There were 350 and 354 biopsies in the two 12-month periods immediately preceding the introduction of the new contract (April 1990) compared with 983 in the 12-month post-contract study period. Of the 983 lesions, 14 (1.4%) were malignant. The clinical ...

Update: Primary care is not the same as primary health care, or is it?

As primary health care (PHC) evolves from its original conceptual level enunciated in 1978 at Alma-Ata to its present formal body of knowledge and practice, 2 definitional problems arise: whether PHC is a transient jargon or label attached to nothing or whether the older, more restricted term primary care (PC) is the same as PHC. The 1st problem has been rendered irrelevant, but the 2nd remains unsolved. Some controversy exists in both literature and practice. Some health care professionals, especially general practitioners, use the terms interchangeably. This may be because of historic traditions based on the biomedical model of education and practice. The term primary care is credited to the Lord Dawson report of 1920, concerned with the reorganization of medical services in England which resulted in the setting up of health centers. Since 1960 under the National Health Service, general practitioners provided curative and preventive services on a 1st-contact medical basis and by 1962 the term was used to denote general practice. This tradition could have then spread to other western countries, including the US and to developing countries. To humanize this biomedical model, Engel proposed the biopsychosocial model which takes into account the biomedical aspects of disease, the patients' social context, their perception of illness and the interaction of the physician and the health care system. This increased health awareness contributed to the evolution of PHC, which evolved from small-scale experiments. A graphic representation of the relationship between primary (medical) care and primary health care illustrates the various consumer levels and the health care system. The multi-disciplinary concept of primary health care is not interchangeable with primary care.

The British National Health Service; general practitioner services.

The British National Health Service General Practitioner Services Affiliation J. S. Collings CopyRight*Presented at a Joint Session of the Dental Health, Medical Care, and Public Health Nursing Sections of the American Public Health Association, at the Seventy-seventh Annual Meeting in New York, N. Y., October 27, 1949. https://doi.org/10.2105/AJPH.40.2.165 Published Online: October 03, 2011