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1.  Poor uptake of primary healthcare registration among recent entrants to the UK: a retrospective cohort study 
BMJ Open  2012;2(4):e001453.
Objectives
Uptake of healthcare among migrants is a complex and controversial topic; there are multiple recognised barriers to accessing primary care. Delays in presentation to healthcare services may result in a greater burden on costly emergency care, as well as increased public health risks. This study aimed to explore some of the factors influencing registration of new entrants with general practitioners (GPs).
Design
Retrospective cohort study.
Setting
Port health screening at Heathrow and Gatwick airports, primary care.
Participants
252 559 new entrants to the UK, whose entry was documented by the port health tuberculosis screening processes at Heathrow and Gatwick. 191 had insufficient information for record linkage.
Primary outcome measure
Registration with a GP practice within the UK, as measured through record linkage with the Personal Demographics Service (PDS) database.
Results
Only 32.5% of 252 368 individuals were linked to the PDS, suggesting low levels of registration in the study population. Women were more likely to register than men, with a RR ratio of 1.44 (95% CI 1.41 to 1.46). Compared with those from Europe, individuals of nationalities from the Americas (0.43 (0.39 to 0.47)) and Africa (0.74 (0.69 to 0.79)) were less likely to register. Similarly, students (0.83 (0.81 to 0.85)), long-stay visitors (0.82 (0.77 to 0.87)) and asylum seekers (0.46 (0.42 to 0.51)) were less likely to register with a GP than other migrant groups.
Conclusions
Levels of registration with GPs within this selected group of new entrants, as measured through record linkage, are low. Migrant groups with the lowest proportion registered are likely to be those with the highest health needs. The UK would benefit from a targeted approach to identify the migrants least likely to register for healthcare and to promote access among both users and service providers.
Article summary
Article focus
Previous studies have suggested that access to health services for refugees and asylum seekers is difficult.
There are limited data on access to primary care among other migrant groups.
This study aimed to explore some of the factors influencing registration of new entrants with GPs.
Key messages
Our study indicates that less than a third (32.5%) of new entrants who are eligible for tuberculosis screening at ports register with a GP.
Registration rates need to be improved by targeting resources to particular subgroups (eg, students and asylum seekers) and increasing awareness of eligibility for primary care among both migrants and GPs.
Strengths and limitations of this study
Previous studies have largely focused on asylum seekers and refugees, whereas we examined a range of migrant groups.
Primary care registration uptake may have been underestimated for those who migrated to Scotland or Northern Ireland, although these individuals represented only a small proportion (2.7%) of our data set.
Port health services only screen entrants from countries with a high incidence of tuberculosis; thus, our results are not generalisable beyond these countries. However, these populations are likely to represent those with the greatest health needs.
doi:10.1136/bmjopen-2012-001453
PMCID: PMC4400681  PMID: 22869094
2.  Rapid estimation of excess mortality: nowcasting during the heatwave alert in England and Wales in June 2011 
Background
A Heat-Health Watch system has been established in England and Wales since 2004 as part of the national heatwave plan following the 2003 European-wide heatwave. One important element of this plan has been the development of a timely mortality surveillance system. This article reports the findings and timeliness of a daily mortality model used to ‘nowcast’ excess mortality (utilising incomplete surveillance data to estimate the number of deaths in near-real time) during a heatwave alert issued by the Met Office for regions in South and East England on 24 June 2011.
Methods
Daily death registrations were corrected for reporting delays with historical data supplied by the General Registry Office. These corrected counts were compared with expected counts from an age-specific linear regression model to ascertain if any excess had occurred during the heatwave.
Results
Excess mortality of 367 deaths was detected across England and Wales in ≥85-year-olds on 26 and 27 June 2011, coinciding with the period of elevated temperature. This excess was localised to the east of England and London. It was detected 3 days after the heatwave.
Conclusion
A daily mortality model was sensitive and timely enough to rapidly detect a small excess, both, at national and regional levels. This tool will be useful when future events of public health significance occur.
doi:10.1136/jech-2011-200962
PMCID: PMC3433219  PMID: 22766783
Heatwave; excess mortality; nowcasting; influenza; mortality; epidemiology
3.  Seroepidemiologic Study of Pandemic (H1N1) 2009 during Outbreak in Boarding School, England 
Emerging Infectious Diseases  2011;17(9):1670-1677.
TOC Summary: Prophylactic antiviral agents lower the odds of acute respiratory infection but not serologic infection.
Keywords: pandemic, influenza, A/H1N1, pandemic (H1N1) 2009, seroepidemiology, outbreak, serology, asymptomatic, prophylaxis, antiviral agents, vaccine, viruses, research
We conducted a seroepidemiologic study during an outbreak of pandemic (H1N1) 2009 in a boarding school in England. Overall, 353 (17%) of students and staff completed a questionnaire and provided a serum sample. The attack rate was 40.5% and 34.1% for self-reported acute respiratory infection (ARI). Staff were less likely to be seropositive than students 13–15 years of age (staff 20–49 years, adjusted odds ratio [AOR] 0.30; >50 years AOR 0.20). Teachers were more likely to be seropositive than other staff (AOR 7.47, 95% confidence interval [CI] 2.31–24.2). Of seropositive persons, 44.6% (95% CI 36.2%–53.3%) did not report ARI. Conversely, of 141 with ARI and 63 with influenza-like illness, 45.8% (95% CI 37.0%–54.0%) and 30.2% (95% CI 19.2%–43.0%) had negative test results, respectively. A weak association was found between seropositivity and a prophylactic dose of antiviral agents (AOR 0.55, 95% CI 0.30–0.99); prophylactic antiviral agents lowered the odds of ARI by 50%.
doi:10.3201/eid1709.100761
PMCID: PMC3322048  PMID: 21888793
4.  Public health professionals' perceptions toward provision of health protection in England: a survey of expectations of Primary Care Trusts and Health Protection Units in the delivery of health protection 
BMC Public Health  2006;6:297.
Background
Effective health protection requires systematised responses with clear accountabilities. In England, Primary Care Trusts and the Health Protection Agency both have statutory responsibilities for health protection. A Memorandum of Understanding identifies responsibilities of both parties, but there is a potential lack of clarity about responsibility for specific health protection functions. We aimed to investigate professionals' perceptions of responsibility for different health protection functions, to inform future guidance for, and organisation of, health protection in England.
Methods
We sent a postal questionnaire to all health protection professionals in England from the following groups: (a) Directors of Public Health in Primary Care Trusts; (b) Directors of Health Protection Units within the Health Protection Agency; (c) Directors of Public Health in Strategic Health Authorities and; (d) Regional Directors of the Health Protection Agency
Results
The response rate exceeded 70%. Variations in perceptions of who should be, and who is, delivering health protection functions were observed within, and between, the professional groups (a)-(d). Concordance in views of which organisation should, and which does deliver was high (≥90%) for 6 of 18 health protection functions, but much lower (≤80%) for 6 other functions, including managing the implications of a case of meningitis out of hours, of landfill environmental contamination, vaccination in response to mumps outbreaks, nursing home infection control, monitoring sexually transmitted infections and immunisation training for primary care staff. The proportion of respondents reporting that they felt confident most or all of the time in the safe delivery of a health protection function was strongly correlated with the concordance (r = 0.65, P = 0.0038).
Conclusion
Whilst we studied professionals' perceptions, rather than actual responses to incidents, our study suggests that there are important areas of health protection where consistent understanding of responsibility for delivery is lacking. There are opportunities to clarify the responsibility for health protection in England, perhaps learning from the approaches used for those health protection functions where we found consistent perceptions of accountability.
doi:10.1186/1471-2458-6-297
PMCID: PMC1712342  PMID: 17156421
5.  Lessons of a hip failure 
BMJ : British Medical Journal  1998;316(7149):1985.
PMCID: PMC1113428  PMID: 9641959
7.  One car down 
BMJ : British Medical Journal  1992;304(6829):780-781.
PMCID: PMC1881596

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