BMJ 2014;348:g2474 doi: 10.1136/bmj.g2474 (Published 28 March 2014)
Page 1 of 2
Feature
FEATURE MEDICINE AND THE MEDIA
NHS England’s winter campaign: is earlier better? This £3m campaign recommends earlier, self care for coughs and colds—but what evidence is there that such a message can improve health outcomes without causing harm, asks Margaret McCartney Margaret McCartney general practitioner, Glasgow Is earlier better? NHS England thinks so. It launched a £3m (€3.6m; $5m) campaign in January 2014 with the stated aim “to persuade people not to store up health problems and to seek advice early,” and to encourage people to “get advice on minor ailments from the community pharmacy service” for symptoms such as “bad cough, wheezing, a cold or sore throat.”1
NHS England said that the campaign was partly a response to the 2013 Keogh Urgent and Emergency Care Review, which highlighted that more older people were being admitted to hospital.2 The campaign included advertising through pharmacies, newspapers, radio, and social media, and its press release lauded “better self and family care, early recognition of illness, and urgent access to medication, primary and community care.” In the press release Keith Willett, NHS England’s director for acute episodes of care, said, “We see . . . so many people who have not had or sought the help they need early enough . . . Too many people make the mistake of soldiering on . . . Unfortunately this can lead to an unnecessary stay in hospital.”1
But does earlier pharmacy treatment of winter infections result in fewer hospital stays? NHS Choices makes particular mention of colds, sore throats, asthma, norovirus, and flu.3
The Keogh review stated that a fifth of GP consultations (18%, or 51 million a year) “could largely have been dealt with through self care and support from community pharmacy services.”4 This claim has been repeated in parliament.5
The statistic comes from research authored by the Self Care Forum6—an organisation sponsored by the Proprietary Association of Great Britain, which represents over-the-counter medicine manufacturers.7 The forum’s research refers to a study that searched the standard UK clinical terminology—the Read codes—from 130 general practices for “minor ailment.” It deemed prescriptions for over-the-counter medicines potentially unnecessary, noting “the potential for substantial cost savings.”8 “Minor ailments” included psoriasis, migraine, headache, and indigestion. This study was therefore entirely unable to draw conclusions about whether patients had presented appropriately to general practice; about the potential harms of patients avoiding general
practice; or about whether prescription drugs would have made for better care. And considering many so called “minor” symptoms have many potential causes, “minor ailments” may be recognisable only in retrospect.
“A common problem with health education media campaigns is that they often impact most on the behaviours of the ‘worried well’ rather than those who are actually unwell and disadvantaged,” said Lucie Rychetnik, associate professor at the School of Medicine, University of Notre Dame in Sydney, Australia. She added that people at risk didn’t always act in their own best interests: “They don’t have the money, transport, mental or physical capacity, support, and so on, to act in health promoting ways,” she told the BMJ. “Thus, telling such people to go to a chemist early (a) may not help them to get there, (b) may make them feel guilty if they don’t go and then they end up in hospital, or (c) may cause them to just spend money on products that make no difference anyway.”
Note also the recent efforts to reduce the unnecessary use of antibiotics for viral infections—in particular, an attempt to demedicalise self limiting illnesses that are a part of normal life. Evidence has also shown that over-the-counter cough mixtures do not work.9 So, does encouraging earlier presentation to a pharmacy—which may lack drugs that can help—improve our health, or threaten it?
The “zombie statistic” of a fifth of primary care consultations being unnecessary is not the only problem with the philosophy underlying NHS England’s campaign. The Keogh review claimed that “if more members of the public are supported to self care and self manage, fewer patients will access unscheduled care within the same episode of care.”10 However, it assumed this on the basis of a qualitative study that sought patients’ views about out of hours care that was not designed to test this hypothesis. This evidence does not support the “earlier is better” campaign.11 Additionally, even though evidence has shown that raising doses of inhaled medication according to asthma symptoms may reduce unplanned hospital admissions, the same approach has not been shown to work for other chronic conditions.12
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g2474 doi: 10.1136/bmj.g2474 (Published 28 March 2014)
Page 2 of 2
FEATURE
Willett told the BMJ that the campaign’s message was “crucial” because older people were at high risk of admission to emergency departments compared with the general population. He said, “An early GP visit by a patient with an existing lung condition, who is feeling unwell, may lead to a reminder to follow a self management plan or an amendment to the plan if necessary. Pharmacists can advise people what symptoms to look out for and what steps they can take to control them.” However, NHS England has encouraged pharmacy visits for a wide range of illnesses. Pharmacists are generally accessible, but might the people who visit them end up purchasing non-evidence-based over-the-counter preparations, rather than seeking professional advice? We spend an estimated annual £500m on cough and cold remedies in the United Kingdom each year.13 Without careful investigation it is hard to know what the effect of the campaign might be and what costs the public may incur.
NHS England told the BMJ that it had tested its campaign with focus groups and would evaluate attendance rates at pharmacies. But shouldn’t NHS England have gathered better evidence before running the campaign? Rychetnik thinks so. She told the BMJ, “We need evidence that going to a chemist early actually does reduce hospital admissions and improve health outcomes. The efficacy . . . should certainly be demonstrated before it is scaled up and rolled out nationally, particularly as the cost is not just that of the campaign, but that of increased out-of-pocket costs to patients. And could it lead to patients delaying visits to their doctor, and using ineffective and expensive over-the-counter products instead? Do the benefits of this type of media campaign outweigh the costs?” There is no reason why interventions such as “earlier better” cannot be randomised and tested; and, given the resources involved, the potential for harm, and the likelihood for ongoing seasonal stress on the NHS, it would be unethical not to.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am an NHS GP. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4
5 6 7 8 9 10
11 12 13
NHS England. “The earlier, the better” say top doctors as NHS England launches first public health campaign. 18 Jan 2014. www.england.nhs.uk/2014/01/18/the-earlier-thebetter-campaign/. NHS England. Keogh urgent and emergency care review. 13 Nov 2013. www.nhs.uk/ NHSEngland/keogh-review/Pages/published-reports.aspx. NHS Choices. Feeling under the weather this winter? www.nhs.uk/asap#winter-healthadvice. NHS England. Transforming urgent and emergency care services in England. Urgent and emergency care review, end of phase 1 report, appendix 1. 13 Nov 2013. www.nhs.uk/ NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%201.EvBase.FV. pdf. Hansard. 20 Nov 2013. www.publications.parliament.uk/pa/cm201314/cmhansrd/ cm131120/halltext/131120h0001.htm. Self Care Forum. Self care: the story so far. www.selfcareforum.org/wp-content/uploads/ 2012/08/aboutselfcare.pdf. Self Care Forum. About us. www.selfcareforum.org/about-us/. Pillay N, Tisman A, Kent T, Gregson J. The economic burden of minor ailments on the National Health Service in the UK. Self Care J . 2010;1:105-6. Smith SM, Schroeder K, Fahey T. Over the counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev 2012. doi:10. 1002/14651858.CD001831.pub4. NHS England. High quality care for all, now and for future generations: transforming urgent and emergency care services in England. The evidence base from the urgent and emergency care review. www.england.nhs.uk/wp-content/uploads/2013/06/urg-emergcare-ev-bse.pdf. Poole R, Gamper A, Porter A, Egbunike J, Edwards A. Exploring patients’ self reported experiences of out of hours primary care and their suggestions for improvement: a qualitative study. Fam Pract. 2011;28:210-9. Purdy S, Paranjothy S, Huntley A, Thomas R, Mann M, Huws D, et al. Interventions to prevent unplanned hospital admission: a series of systematic reviews. June 2012. www. bristol.ac.uk/primaryhealthcare/docs/projects/unplannedadmissions.pdf. Mintel. Customers cough up for remedies as flu season starts early. 23 Oct 2009. www. mintel.com/press-centre/beauty-and-personal-care/consumers-cough-up-for-remediesas-flu-season-starts-early.
Cite this as: BMJ 2014;348:g2474 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Feature
FEATURE MEDICINE AND THE MEDIA
NHS England’s winter campaign: is earlier better? This £3m campaign recommends earlier, self care for coughs and colds—but what evidence is there that such a message can improve health outcomes without causing harm, asks Margaret McCartney Margaret McCartney general practitioner, Glasgow Is earlier better? NHS England thinks so. It launched a £3m (€3.6m; $5m) campaign in January 2014 with the stated aim “to persuade people not to store up health problems and to seek advice early,” and to encourage people to “get advice on minor ailments from the community pharmacy service” for symptoms such as “bad cough, wheezing, a cold or sore throat.”1
NHS England said that the campaign was partly a response to the 2013 Keogh Urgent and Emergency Care Review, which highlighted that more older people were being admitted to hospital.2 The campaign included advertising through pharmacies, newspapers, radio, and social media, and its press release lauded “better self and family care, early recognition of illness, and urgent access to medication, primary and community care.” In the press release Keith Willett, NHS England’s director for acute episodes of care, said, “We see . . . so many people who have not had or sought the help they need early enough . . . Too many people make the mistake of soldiering on . . . Unfortunately this can lead to an unnecessary stay in hospital.”1
But does earlier pharmacy treatment of winter infections result in fewer hospital stays? NHS Choices makes particular mention of colds, sore throats, asthma, norovirus, and flu.3
The Keogh review stated that a fifth of GP consultations (18%, or 51 million a year) “could largely have been dealt with through self care and support from community pharmacy services.”4 This claim has been repeated in parliament.5
The statistic comes from research authored by the Self Care Forum6—an organisation sponsored by the Proprietary Association of Great Britain, which represents over-the-counter medicine manufacturers.7 The forum’s research refers to a study that searched the standard UK clinical terminology—the Read codes—from 130 general practices for “minor ailment.” It deemed prescriptions for over-the-counter medicines potentially unnecessary, noting “the potential for substantial cost savings.”8 “Minor ailments” included psoriasis, migraine, headache, and indigestion. This study was therefore entirely unable to draw conclusions about whether patients had presented appropriately to general practice; about the potential harms of patients avoiding general
practice; or about whether prescription drugs would have made for better care. And considering many so called “minor” symptoms have many potential causes, “minor ailments” may be recognisable only in retrospect.
“A common problem with health education media campaigns is that they often impact most on the behaviours of the ‘worried well’ rather than those who are actually unwell and disadvantaged,” said Lucie Rychetnik, associate professor at the School of Medicine, University of Notre Dame in Sydney, Australia. She added that people at risk didn’t always act in their own best interests: “They don’t have the money, transport, mental or physical capacity, support, and so on, to act in health promoting ways,” she told the BMJ. “Thus, telling such people to go to a chemist early (a) may not help them to get there, (b) may make them feel guilty if they don’t go and then they end up in hospital, or (c) may cause them to just spend money on products that make no difference anyway.”
Note also the recent efforts to reduce the unnecessary use of antibiotics for viral infections—in particular, an attempt to demedicalise self limiting illnesses that are a part of normal life. Evidence has also shown that over-the-counter cough mixtures do not work.9 So, does encouraging earlier presentation to a pharmacy—which may lack drugs that can help—improve our health, or threaten it?
The “zombie statistic” of a fifth of primary care consultations being unnecessary is not the only problem with the philosophy underlying NHS England’s campaign. The Keogh review claimed that “if more members of the public are supported to self care and self manage, fewer patients will access unscheduled care within the same episode of care.”10 However, it assumed this on the basis of a qualitative study that sought patients’ views about out of hours care that was not designed to test this hypothesis. This evidence does not support the “earlier is better” campaign.11 Additionally, even though evidence has shown that raising doses of inhaled medication according to asthma symptoms may reduce unplanned hospital admissions, the same approach has not been shown to work for other chronic conditions.12
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g2474 doi: 10.1136/bmj.g2474 (Published 28 March 2014)
Page 2 of 2
FEATURE
Willett told the BMJ that the campaign’s message was “crucial” because older people were at high risk of admission to emergency departments compared with the general population. He said, “An early GP visit by a patient with an existing lung condition, who is feeling unwell, may lead to a reminder to follow a self management plan or an amendment to the plan if necessary. Pharmacists can advise people what symptoms to look out for and what steps they can take to control them.” However, NHS England has encouraged pharmacy visits for a wide range of illnesses. Pharmacists are generally accessible, but might the people who visit them end up purchasing non-evidence-based over-the-counter preparations, rather than seeking professional advice? We spend an estimated annual £500m on cough and cold remedies in the United Kingdom each year.13 Without careful investigation it is hard to know what the effect of the campaign might be and what costs the public may incur.
NHS England told the BMJ that it had tested its campaign with focus groups and would evaluate attendance rates at pharmacies. But shouldn’t NHS England have gathered better evidence before running the campaign? Rychetnik thinks so. She told the BMJ, “We need evidence that going to a chemist early actually does reduce hospital admissions and improve health outcomes. The efficacy . . . should certainly be demonstrated before it is scaled up and rolled out nationally, particularly as the cost is not just that of the campaign, but that of increased out-of-pocket costs to patients. And could it lead to patients delaying visits to their doctor, and using ineffective and expensive over-the-counter products instead? Do the benefits of this type of media campaign outweigh the costs?” There is no reason why interventions such as “earlier better” cannot be randomised and tested; and, given the resources involved, the potential for harm, and the likelihood for ongoing seasonal stress on the NHS, it would be unethical not to.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am an NHS GP. Provenance and peer review: Commissioned; not externally peer reviewed. 1 2 3 4
5 6 7 8 9 10
11 12 13
NHS England. “The earlier, the better” say top doctors as NHS England launches first public health campaign. 18 Jan 2014. www.england.nhs.uk/2014/01/18/the-earlier-thebetter-campaign/. NHS England. Keogh urgent and emergency care review. 13 Nov 2013. www.nhs.uk/ NHSEngland/keogh-review/Pages/published-reports.aspx. NHS Choices. Feeling under the weather this winter? www.nhs.uk/asap#winter-healthadvice. NHS England. Transforming urgent and emergency care services in England. Urgent and emergency care review, end of phase 1 report, appendix 1. 13 Nov 2013. www.nhs.uk/ NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%201.EvBase.FV. pdf. Hansard. 20 Nov 2013. www.publications.parliament.uk/pa/cm201314/cmhansrd/ cm131120/halltext/131120h0001.htm. Self Care Forum. Self care: the story so far. www.selfcareforum.org/wp-content/uploads/ 2012/08/aboutselfcare.pdf. Self Care Forum. About us. www.selfcareforum.org/about-us/. Pillay N, Tisman A, Kent T, Gregson J. The economic burden of minor ailments on the National Health Service in the UK. Self Care J . 2010;1:105-6. Smith SM, Schroeder K, Fahey T. Over the counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev 2012. doi:10. 1002/14651858.CD001831.pub4. NHS England. High quality care for all, now and for future generations: transforming urgent and emergency care services in England. The evidence base from the urgent and emergency care review. www.england.nhs.uk/wp-content/uploads/2013/06/urg-emergcare-ev-bse.pdf. Poole R, Gamper A, Porter A, Egbunike J, Edwards A. Exploring patients’ self reported experiences of out of hours primary care and their suggestions for improvement: a qualitative study. Fam Pract. 2011;28:210-9. Purdy S, Paranjothy S, Huntley A, Thomas R, Mann M, Huws D, et al. Interventions to prevent unplanned hospital admission: a series of systematic reviews. June 2012. www. bristol.ac.uk/primaryhealthcare/docs/projects/unplannedadmissions.pdf. Mintel. Customers cough up for remedies as flu season starts early. 23 Oct 2009. www. mintel.com/press-centre/beauty-and-personal-care/consumers-cough-up-for-remediesas-flu-season-starts-early.
Cite this as: BMJ 2014;348:g2474 © BMJ Publishing Group Ltd 2014
Subscribe: http://www.bmj.com/subscribe
