This post is written by Sophie Park (Professor of Primary Care and Medical Education)  and Dr Emily Owen (Research Assistant, Community Pharmacy and General Practice) 

The Society of Academic Primary Care (SAPC) in its 50th year, have collaborated with the Association for the Study of Medical Education (ASME) to host a joint conference event. Our SAPC Education Research Special Interest Group (SIG) met on Tuesday 5th July 2022 to discuss spaces for practitioner-informed research and enquiry.

It is sometimes hard to know where to start. You are a practitioner and have an area of keen interest, but feel the topic is so vast, any firm plans about research feel beyond reach. At the SIG, a group of scientists and practitioner ‘insider researchers’ met to discuss ways of beginning to bring a research idea into focus.

Stakeholder & Patient and Public involvement (PPI)

As practitioners, we often hold a view or perspective which relates to our own embodied experience and meaning-making processes about particular events. Reaching out at the outset of the project is crucial. Attentive listening to how others experience an issue is important, to help understand what others feel the key and important problems are. Continuing these conversations then enables a dynamic movement between inductive (emergent) response to generated data and deductive (pre-determined) focus on the data, embracing a range of views and concerns.

Once you start to have conversations, consider how PPI/stakeholder perspectives might shape how you approach the literature and data about this topic. How might this focus your project and analysis? We shared an on-going review (PROSPERO: CRD42022314280) exploring collaborative and integrated working between General Practice and Community Pharmacies. Having conversations with PPI/stakeholders is informing possible ways of thinking about patient care (access, help-seeking behaviour, psychological safety, continuity); working with and across multi-disciplinary colleagues; and professional development and education. These conversations support an explicit and reflexive movement between experiential priorities and the existing evidence data, helping to prioritise ways of drawing together analytical categories.

Rather than feeling anxious about the impact of your own and others’ experience on the production of data, celebrate your growing insights and understandings about these experiences, and be reflexive about how they are shaping your views during the production of the research protocol, project, and analysis. You will not be able to incorporate all PPI/stakeholder views and agendas, so establish clear expectations about the purpose of your conversations. Enjoy the contrast of views and note how these differences emerge. Might this provide you a new avenue to explore your topic?

Theory

We tend to think that whatever view we hold is ‘normal’. It is helpful, therefore, to share and discuss your ideas with others. These discussions will make visible areas of ‘cognitive dissonance’ or tensions and help to build insight about the particular theories or evidence-base you are using. Start to consider contrasting perspectives. How do these differ from yours? Is your view still helpful to hold, or might you begin to transition to a different position in your approach? This curiosity and movement between different ‘ways of knowing’ are the basis of ‘critical thinking’. These help to cultivate an appetite to understand other positions, supporting you to build a rationale for why you are approaching your research in a particular way, and how you plan to produce particular forms of knowledge outputs or artefacts.

Methods

Some approaches to research will feel more comfortable than others. Be brave and consider multiple options before you plan your project. Consider what it is you want to know, then how a different approach might enable you to know about this topic in a different way. How might each contribute to your overall aims about contribution to practice and policymaking, and moving your disciplinary knowledge field forwards? For example, do you want to create an evaluation project? These often aim to measure the effectiveness of an ‘intervention’, then perhaps make comparative claims. Instead, you might want to conceptualise it as a process, making visible the nature of that process through more exploratory or in-depth qualitative methodologies.

There is no ‘right answer’, and each project/approach will contribute in different and particular ways. What is important, is that you consider these aspects in advance, so that you can plan and anticipate the challenges and opportunities of each theoretical and practical approach from the outset.

Be Realistic

At the beginning, it can feel completely over-whelming. The planning process can feel endless: you want to move onto the practical ‘doing’ of the project as soon as possible. Be patient. Use your enthusiasm to move through the processes above: engagement and dialogue with stakeholders/PPI; reading, and re-reading literature to identify your gap; and mapping the available methods and potential knowledge outputs. Second, keep the project feasible. A focused project will enable you to progress to the next project. Ask yourself what is most important to you at this moment in time and start from there.

Peer Support

Lastly, utilise peer support during your research planning. Enjoy the creative production of your project and share your challenges. Colleagues may have experienced something similar or be able to highlight where you are identifying something innovative in your area of expertise. Through presenting your ideas to an audience, you can shift your thinking about a project: having been immersed in a particular topic, it is sometimes helpful to realise which areas are new or interesting to others. These conversations can also help you to focus your dissemination and spaces for impacting future research, practice, and policy.

Thank you to all who attended the SIG, we look forward to meeting again soon.

This blog post is written by Melvyn Jones (A Clinical Associate Professor in General Practice), Surinder Singh (a Clinical Senior Lecturer at PCPH), and See Chai Carol Chan and Jack Shi Jie Yuan (both medical students).

This summer a very slowly gestating project came to fruition with the publication in the BMJopen of a study exploring the influences at medical schools on students with respect to GP career choices (see here). Surinder Singh and myself quite a few years ago (2017) thought that an anthropological approach using our students to capture these drivers of student carer choice might be quite a useful addition to the field, on the back of the NHS Wass report “By choice not by chance”.  At the same time the AcaMedics group (a multi institutional collaboration to support students developing research skills) was looking for potential projects. We set our plans and were lucky to be selected by two highly able UCL medical students (Jack Shi Jie Yuan  and See Chai Carol Chan) to work on the project.  Meanwhile across London at Imperial a very similar project was being undertaken.  It took Sophie Park to join the dots and make this a cross institutional project- key to improving the generalisability of our findings.

Getting ethics was tricky though.  Would we need consent to use quotes from someone making pejorative comments about general practice as a career?  Clearly this would never happen, but thankfully the ethics committee agreed that the anonymised observation and reflection occurring away from the clincal setting was acceptable.

Rolling forward via presentations and posters at the UCL Education conference in 2018, the Trainees in the Association for the Study of Medical Education (TASME 2018)  and SAPC Madingley hall conference helped us shape our thinking.  Writing workshops helped refine our argument. However, publication proved much more difficult with a straight rejection and then a very long drawn out peer review, eventually leading to another rejection.   A key motivation for our students was to have something to put in their publication box on their NHS junior doctor Foundation Programme application, but by this stage they had all graduated and moved on.  It took a final push by Ravi Parekh at Imperial assisted by myself and Surinder to have a good fresh look at the manuscript, the data and the peer reviews and to decide it was with another go.  So in the summer 2021 it finally appeared.

What are the messages from the study?   Some of the findings were there before- students feeling a GP career was the default, the fall back position. For students used to competing for everything this seems like defeat. The interesting observation was the student’s perception of the internalised process of being a primary care physician. The fact that the GP sits and the patient comes to them was perceived as being too passive to students used to the swarm of the ward round buzzing around hospitals. The internal process of thinking about clinical decisions such as how to balance treating a patient’s heart failure without worsening their kidney function or making them fall over as their blood pressure drops, was invisible to the students. It was only when the students were sitting in the consulting hot seat did they begin to see the considerable intellectual challenge to many primary care consultations.   But were they exposed to “bad mouthing” of general practice?  Yes to some extent, but interestingly they were also exposed to hospital clinicians who talked up the role of general practice and the challenges to doing it well.

It was always challenging for students to undertake their own research project (see here). However it is a great shame that students appear to be completely marginalised since Covid when it comes to undertaking research projects. Recent new guidance from the NHS Research Authority prevents undergraduates from conducting research.  Thus, perhaps the ultimate conclusion for our study – which has come to light after publication – is that we’re faced with far fewer opportunities to prepare and encourage the next generation of would-be researchers.

Working with students on research projects is a however great experience but the time frame for ethics and sluggish peer review processes can be a real issue when they have fixed deadlines like revising for finals, moving on as junior doctors and the almost complete lack of headspace to think about research when they are enveloped in working as an NHS foundation doctor.  Find a project however, with a realistic outcome and timeframe and you will find a rich seam of motivated talented individuals who are keen to contribute.

 “I’ve seen so many people die…so much of it over the last 19 years…And it’s [the project] invaluable. It should have been done years ago” – Hostel Staff member

In this month’s post, Dr Caroline Shulman and Dr Megan Armstrong discuss their work on embedding palliative specialists into homeless hostels across the UK.

Dr Megan Armstrong is a Senior Research Fellow now managing the PD-Care study and is PI of ‘optimising self-management of long-term multi-morbidity in people experiencing socioeconomic deprivation’.

Dr Caroline Shulman is a GP in Homeless and Inclusion Health and a Honorary Senior Lecturer at UCL. Caroline is continuing to roll this project out, including providing training for hospices on homelessness issues.

People experiencing homelessness have a high rate of multi-morbidity, frailty and age-related conditions at a young age and are at high risk of dying young [1,2]. Previous work found people living in homeless hostels often had severe physical and mental health problems, often complicated by substance misuse, and despite the complexity of need they almost never have access to palliative care support [3]. This lack of palliative care support is due to variety of reasons including hospices being unable to support those with addictions and mental health issues, uncertainty about when someone might be palliative, and hostel staff feeling uncomfortable about discussing palliative care [3]. For many people experiencing homelessness, the hostel can be their preferred place of care as they often consider this to be the closest place they have to a home [4]. The lack of palliative care support and appropriate places of care leads to hostel staff supporting very unwell people with complex needs.

Our project aimed to improve access to high quality care and support for people experiencing homelessness who have advanced ill health and to reduce the burden on frontline staff, by embedding training, support, and a multidisciplinary team approach into hostels [5]. Palliative care nurses and social workers attended an intensive two-day training course into homeless issues. Free online training resources were shared (www.homelesspalliativecare.com); this includes tools that can support hostel staff to work with people with palliative care needs. Following training, we held a stakeholder event for homelessness, health, social care and addictions commissioners and providers. This resulted in useful connections being made between different organisations. Following this event, the palliative care staff spent 1-2 days per month in the hostels.

Palliative care staff trained and supported hostel staff to identify red flags, consider which residents they were concerned about who may benefit from a multidisciplinary approach and supported them to involve other members of the multidisciplinary team in the care of their residents. Hostel staff felt much more confident and empowered to approach other agencies as a result of the project.

“I think everyone is just a little bit braver now, to step forward and [to outside agencies] be like, actually, this is how it is supposed to be. You’re not supposed to be telling us that.” – Hostel staff member

The palliative care teams also helped staff focus on a holistic person-centred approach, exploring what ‘living well’ means to someone. As a result of the support provided, hostel staff were happy to support someone who had a new advanced cancer diagnosis, to have a planned death within the hostel. This was the resident’s choice and prior to the project, this would not have been considered.

“Initially when we think that someone is going to die, we would have said “no,no,no, we  need to move them on quickly, we don’t want them dying within the hostel” ..but then we started to change our way of thinking because of this…we did start saying, well yes this is his home” – Hostel staff member

There is a need to refocus how we support people experiencing homelessness with advanced ill health or complex health needs. Not everyone will recover so to work in a more person-centred way we need to explore what insights people have around their illness and explore what living well means to them. If recovery is not an option, the least we can do is support someone to have a dignified and respectful death.

References

1. Rogans-Watson R, Shulman C, Lewer D, Armstrong M, & Hudson B. (2020). Premature frailty, geriatric conditions and multimorbidity among people experiencing homelessness: a cross-sectional observational study in a London hostel. Housing, Care and Support Vol 23 NO. 3/4 2020, pp. 77-91
2. Aldridge RW, Story A, Hwang SW, et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet 2018;391:241–50.
3. Shulman, C., Hudson, B. F., Low, J., Hewett, N., Daley, J., Kennedy, P., Brophy, N. & Stone, P. (2018). End-of-life care for homeless people: a qualitative analysis exploring the challenges to access and provision of palliative care. Palliative medicine, 32(1), 36-45.
4. Hudson, B. F., Flemming, K., Shulman, C., & Candy, B. (2016). Challenges to access and provision of palliative care for people who are homeless: a systematic review of qualitative research. BMC palliative care, 15(1), 1-18.
5. Armstrong, M., Shulman, C., Hudson, B., Brophy, N., Daley, J., Hewett, N., & Stone, P. (2021). The benefits and challenges of embedding specialist palliative care teams within homeless hostels to enhance support and learning: Perspectives from palliative care teams and hostel staff. Palliative Medicine, 02692163211006318.

I have been assured that asking oneself “Why am I doing this?!” is not an experience unique to any one stage of a research career. The key is having a good answer.

At the height of the British summer heat wave, I travelled to Chicago, to give an oral presentation to the Alzheimer’s Association International Conference (AAIC) on a project I’ve joined, funded by the Dunhill Medical Trust, addressing inequality in primary care of people with dementia among UK ethnic groups.

The first phase of the project has already been published in Clinical Epidemiology and found that dementia diagnosis incidence was significantly higher in Black men and women compared to White men and women, respectively, and was significantly lower in Asian women compared to White women. Tra recently wrote a blog on this below. I presented these results along with new results showing inequality by ethnicity in prescribing of certain drugs among patients with dementia.

The presentation itself went smoothly, and I breathed a sigh of relief as I walked off stage. With the nerves and the bright lights out of the way, I was excited to find that a queue of people were keen to talk with me about the project.

Multiple researchers expressed how grateful they were that someone was looking into this area, highlighting that while the demographics of many developed nations are changing, the research has not often kept up. Others wanted to share personal experiences, speaking of the reluctance of family members to seek a diagnosis or medication even as their condition progressed, especially when cultural factors around memory problems and fear of stigma were at play. These conversations made clear that the need to identify inequalities and break down barriers to good quality care was not a problem unique to the UK, but everyone I spoke with reinforced how important it was to see that we’re working on it.

In the midst of Stata code, funding applications, and reviewer comments, we can lose sight of the goal. As researchers, we have the privilege of generating work that can improve peoples’ lives. We can be reminded of that by our Patient & Public Involvement advisors, our colleagues, or a review of the “Impact” section of our own funding application (and hopefully by this blog post). My conversations with a variety of people after my presentation was a wonderful reminder of the goal and impact of this project. I hope you can take a moment today to remember the goal of your work too, because you’re doing this for a good reason!

In this post Tom Hartney, a PhD student at PCPH, talks about the Health Protection Research Unit and its recent Academy day.

The Health Protection Research Unit (HPRU) is a collaboration between universities, including University College London and Imperial College London, and Public Health England (PHE). This is part-funded by the National Institute of Health Research (NIHR) in order to promote high quality multi-disciplinary health research. It was set up in 2012, and supports the funding of PhD students to work on projects related to the HPRU’s research objectives.

These students make up the HPRU Academy – this isn’t a university in itself, but instead represents PhD students based across several universities, working in 10 research units each of which focuses on a different health issue (such as emerging infections or environmental hazards) or methodology (such as modelling or evaluation of interventions). This January saw the first HPRU Academy Retreat, which brought together students from across the country to present results from their work and hear about future plans and priorities for the Academy.

Me, second left, and Josina, third left, at the Academy Retreat with our fellow PhD students from the HPRU in Blood Borne and Sexually Transmitted Infections

Myself and Josina Calliste from PCPH attended, both representing the HPRU in Blood Borne and Sexually Transmitted Infections. With 19 students giving oral presentations, as well as talks from academics and PHE staff, over two days, we knew this would be a packed schedule, but it gave us a chance to meet other students working on public health topics, to talk about our projects and find opportunities to work with them in future.

The format was divided into two types of talks, with those from students talking about their work making up the majority of the programme, and each day introduced and ending with talks from HPRU academics on the public health research landscape and aspects of methodology. The student presentations covered a huge breadth of healthcare topics, from the effects of traffic pollution to the risks from ticks in urban areas, with the research opportunities provided by genomic sequencing being a common theme. Given there was so much to cover, students somehow still managed to convey their enthusiasm for their chosen topic and explain their key results while sticking to time.

Professor Bernie Hannigan gave the PHE perspective on the Academy, emphasising its focus on applied research – identifying gaps in the evidence and addressing them with research outputs – as well as the need for researchers to think about how evidence influences public health policy & practice. Dr Satnam Sagoo, PHE’s Head of Education and Training, discussed routes to develop a career in public health, setting out the options available and ways to enhance transferable skills during the PhD process.

Karen Wilding from the University of Liverpool presented on research ethics and governance, a fundamental aspect of every research project. She described the variety of clinical research governance systems and frameworks, as well as the key considerations for ethics, and resources available for help and advice. Finally, Professor Jackie Cassell from Brighton and Sussex Medical School talked about getting patients and the public involved in research. She described ways to implement this at every stage of the lifespan of the doctorate, some of the challenges involved in healthcare research in general, and on transient and stigmatised conditions in particular. Imaginative approaches to public engagement were illustrated  these using the example of an exhibition on scabies at the Eastbridge Hospital in Canterbury – originally a medieval hospital for pilgrims – set up in collaboration with the Textile Department of the University of Brighton.

To break things up the Retreat included interactive elements – firstly, in the form of an outbreak response exercise led by Dr Ruth Ruggles, Head of Public Health Training at PHE. Dr Ruggles used data from a real outbreak to put students in the role of public health response teams with crucial decisions to make as the outbreak developed. This culminated in a role played press conference, with volunteers fielding tricky questions from the audience on the media and public reaction to the outbreak. Also, students were able to vote online on their favourite talks and poster presentations, with prizes awarded by Professor Tom Solomon from the University of Liverpool on the final day.

Despite the challenge of packing so much into a two day schedule, the inaugural HPRU Academy retreat provided plenty of food for thought on how to use the expertise available within the Academy – here’s looking forward to next year’s event.

This month Rammya Mathew an Academic Clinical Fellow from the Centre for Ageing Population Studies talks about her first and very impressive first time at the SAPC regional Madingley conference which this year we hosted.

This was my first experience of SAPC, and what a fantastic introduction it was. The conference was jam-packed with inspirational speakers, some of whom have paved the way for academic primary care, and many more who look set to be future leaders within the field. The question posed to us by the chair, Professor Elizabeth Murray, was ‘Innovation in a sea of change – will academic primary care sink or swim?’. However, the overwhelming attendance and the enthusiasm among delegates spoke volumes in itself, and provided a sound evidence base for the conclusion, which I will share later.

The opening keynote speech by Professor Martin Marshall challenged our views of traditional research. The need to bridge the gap between the knowledge base that academia provides, and what actually happens in clinical practice was brought to our attention. He introduced the concept of participatory research, and by sharing his own experiences of being an embedded researcher in East London, he demonstrated the impact that this model may have in terms of knowledge creation and mobilisation.

The ‘Dragon’s Den’ was an exciting new addition this year. For some reason, our esteemed judges got slightly confused and enacted the ‘Strictly come dancing’ panel instead. But we had to forgive their mishap, as their sense of humour more than compensated for the error. The calibre of the candidates that were pitching was truly remarkable. Dr Kingshuk Pal from UCL propositioned HELP DIABETES – a fully-fledged online website that supports self management of diabetes. However, the dragons were fierce in expressing their concern that HELP DIABETES would be another tool best suited to those who are already self motivated. The second pitch was by the medical education department at Imperial College London, who were asking for all medi
cal students to go to jail! They put forward a passionate argument that this would improve their understanding of health inequalities and provide experiential learning of working with marginalised groups. This was a moving presentation that tugged at the heart strings of the audience, but the dragons questioned what would be removed from the curriculum in order to make way for this initiative. The last and final pitch was an online pathway, which offered advice, testing and treatment for chlamydia. Being practical and having demonstrated proof of success, it sealed the deal. 

One of the things that stood out to me from the presentations at SAPC this year, was that the conference clearly demonstrated the excellent insights that well-conducted qualitative research can offer. A particular presentation which highlighted this was by, Dr Nadia LLanwarne from Cambridge. She presented the findings of her research, exploring the missed opportunities for diagnosing melanoma in primary care and the patient experience along this journey from initial presentation to diagnosis. I certainly came away from the conference this year, feeling assured that qualitative research is both valuable and necessary – its role was cemented, in terms of putting quantitative research into context and relating it to the real and often ‘messy’ world we face in general practice.

Professor Roger Jones, editor of the BJGP, rounded up the conference with an excellent plenary session. Using his personal story, he talked about the degree of change we have seen in primary care over the years –  across academia, education and clinical practice. It was a real eye-opener! It was encouraging to hear the he still looks forward to going to work everyday and has maintained his enthusiasm for general practice, despite the ever changing working environment. Finally, the conference came to a close and we unanimously concluded that academic primary care was not sinking, nor swimming, but was indeed motoring!

Dr Sophie Park, GP & Senior Lecturer in Primary Care at UCL, was highly commended for the Yvonne Carter Award 2015 for her innovative work in developing a distinct body of educational research in primary care.

Below Joanne Reeves, Amanda Howe and Sophie Park on Thursday 10th July in Oxford at the SAPC ASM.

Ann Liljas talks about her experience of attending a graduate student conference at Cumberland Lodge.

Every year around 30 graduate students in the public health field are invited to a conference at Cumberland Lodge in Windsor Park. This 3-day conference is organised for students by students to provide the opportunity to gain skills within various fields of health research, share ideas and get to know each other. Cumberland Lodge is part of the King George VI and Queen Elizabeth Foundation of St Catherine’s which was set up to provide a sympathetic ambience for students and their lecturers to develop and explore their studies, free of the pressures of time or assessment.

This year’s conference took place between 30 May to 1 June and the theme was Major Public Health Challenges Facing the UK. Three students from Primary Care and Population Health attended; Rosa Lau, Kethakie  Sumathipala and Ann Liljas. There were six sessions on a number of public health topics ranging from depression, cardiovascular disease and dementia to obesity, diabetes and cancer. Each session was delivered by an expert in the field from either UCL or another university in London. The speakers started by providing some background information on their particular topic and why it is an important public health issue. They then moved on to demonstrate what research has been done and what needs to be done to improve that particular health issue.

The conference really provided an opportunity to learn more about various public health issues and an opportunity for networking. Top 3 discussions at the conference included the associated between appetite and increased risk of obesity, why aspirin can reduced the risk of cancer, and the importance of considering other morbidities in people who already have a disease. If you want to find out more about these particular topics, take a look at the papers listed below which are based on studies undertaken by some of the presenters.

Llewellyn, C et al. 2010 Nature of nurture in infant appetite: analysis of the Gemini twin birth cohort. American Journal of Clinical Nutrition. 91(5):1172-1179 Access

Rothwell, PM et al. 2011 Effect of daily aspirin on long-term risk of death due to cancer: analysis of individual patient data from randomised trials. The Lancet. 377(9759):31-41 Access

Haddad, M et al. 2013 Detecting depression in patients with coronary heart disease: a diagnostic evaluation of the PHQ-9 and HADS-D in primary care, findings from the UPBEAT-UK study. PLoS One. 10;8(10):e78493 Access