Increasing hospital admissions for pneumonia have been reported recently but it is not known whether pneumonia incidence rates have increased in the community. To determine whether incidence rates of pneumonia increased in primary care in the United Kingdom from 2002 to 2017, an open cohort study was conducted using electronic health records from the UK Clinical Practice Research Datalink. Clinically diagnosed pneumonia, influenza pneumonia, pleural infection and clinically suspected pneumonia, defined as chest infection treated with antibiotics, were evaluated. Age-standardised and age-specific rates were estimated. Joinpoint regression models were fitted and annual percentage changes (APC) were estimated. There were 70.7 million person-years of follow-up with 120 662 episodes of clinically diagnosed pneumonia, 1 831 005 of clinically suspected pneumonia, 23 814 episodes of influenza pneumonia and 2644 pleural infections over 16 years. The incidence of clinically diagnosed pneumonia increased from 1.50 per 1000 person-years in 2002 to 2.22 per 1000 in 2017. From 2010 to 2017, the APC in age-standardised incidence was 5.1% (95% confidence interval 3.4–6.9) compared with 0.3% (−0.6 to 1.2%) before 2010. Clinically suspected pneumonia incidence rates increased from 2002 to 2008 with an APC 3.8% (0.8–6.9) but decreased with an APC −4.9% (−6.7 to −3.1) from 2009 to 2017. Influenza pneumonia increased in the epidemic year of 2009. There was no overall trend in pleural infection. The results show that clinically diagnosed pneumonia has increased in primary care but there was a contemporaneous decline in recording of clinically suspected pneumonia or ‘chest infection’. Changes in disease labelling practice might partly account for these trends.

There are now 125 million people aged 80 years and over worldwide, projected by the United Nations to grow threefold by 2050. While increases in life expectancy and rapid increases in the older-age population are considered positive developments, the consequential future health care burden represents a leading concern for health services. We revisit Williams’ ‘fair innings’ argument from 1997, in light of technological and demographic changes, and challenge the notion that greater longevity may impose an unfair burden on younger generations. We discuss perspectives on the equity-efficiency trade-off in terms of their implications for the growing over-80 population, as well as society in general. This includes questioning the comparison of treatment cost-effectiveness in younger vs. older populations when using quality-adjusted life years and the transience of life expectancies over generations. While recognising that there will never be a clear consensus regarding societal value judgements, we present empirical evidence on the very elderly that lends support to a stronger anti-ageist stance given current increases in longevity.

South Asian populations are predisposed to early onset of the metabolic syndrome. Lifestyle intervention programmes have demonstrated a reduction in the metabolic syndrome and CVD risk; however, the most effective components of the multi-faceted lifestyle interventions are unknown. We studied 2637 Sri Lankan males (n 1237) and females (n 1380), with a mean BMI of 23·9 (sd 4·2) kg/m2, aged 22·5 (sd 10·0) years, who had participated in a 5-year lifestyle-modification programme to examine the effect of dietary changes on distinct components of the metabolic syndrome. The dietary intervention comprised advice to replace polished starches with unpolished starches, high-fat meat and dairy products with low-fat products and high-sugar beverages and snacks with low-sugar varieties. For the purposes of this analysis, data from the control and intensive lifestyle groups were combined. Anthropometric and biochemical data were recorded, and a FFQ was completed annually. Multiple regression was used to determine the effect of the dietary changes on distinct components of the metabolic syndrome. The ratio unpolished:polished rice was inversely related to change in fasting glucose (β=−0·084, P=0·007) and TAG (β=−0·084, P=0·005) and positively associated with change in HDL-cholesterol (β=0·066, P=0·031) at the 5-year follow-up after controlling for relevant confounders. Red meat intake was positively associated with fasting glucose concentrations (β=0·05, P=0·017), whereas low-fat (β=−0·046, P=0·018) but not high-fat dairy products (β=0·003, P=0·853) was inversely related to glucose tolerance at the follow-up visit. Replacement of polished with unpolished rice may be a particularly effective dietary advice in this and similar populations.

This review concludes that: a) the global burden of disease from non-insulin-dependent diabetes mellitus (NIDDM) cannot be completely estimated at present; b) evidence for the efficacy of key elements of a package of care is still needed; c) generalizing the results of evaluations of costs or effectiveness across different populations is not straightforward; and d) for this complex intervention, the costs and effectiveness of intervention may be highly dependent on methods of organizing care. Addressing this information deficit represents an important task for researchers and health decision makers.

Most evidence on the delivery of diabetes services in primary care has focused on the organization of care rather than on the experiences of health care providers. We evaluated staff satisfaction with respect to access, communication, management advice, and understanding of roles. A postal survey of staff at 35 practices from two inner London primary care organizations was linked to profiles of the practice organization of diabetes care. Data were analysed for 124 staff including 81 doctors and 43 nurses. Only 37 (46%) doctors and 20 (47%) nurses were satisfied with the current system of diabetes care. Overall, there were low levels of satisfaction with access to, communication with, or management advice from other members of the diabetes team. Only 29/81 (36%) of doctors understood clearly either their own role or the role of others but 27/43 (63%) of nurses understood their own role and 23 (53%) understood the role of others. Compared with practices with less satisfied staff, practices where staff were more satisfied showed similar organization of diabetes care in terms of the use of a register, recall system, clinical guidelines, availability of equipment, organization of education programmes or use of audit. Staff were generally dissatisfied with diabetes services, but the level of satisfaction was not associated with practice organization for diabetes care. Since a better team climate has been associated with higher quality care, more work should be done to understand influences on staff satisfaction in the delivery of diabetes care in primary settings.