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Can a self-management intervention facilitated by peer support workers reduce readmission rates to acute care for people discharged from crisis resolution teams

NathanDavies23 August 2018

In this post Louise Marston talks about their recent study published in The Lancet on peer support for reducing readmission among people to acute care for people discharged from crisis resolution teams, which provide intensive home treatment following a crisis.

CORE (CRT Optimisation and RElapse prevention) has been a big part of my working life for a number of years.  It was an NIHR funded programme grant from 2011 to 2017.  One of the work packages was an individually randomised controlled trial supported by Priment Clinical Trials Unit.  The results were published in The Lancet recently.

Why did we do this study?

Crisis resolution teams work in the community to help prevent admission to acute care at times of mental health crisis.  Nationally, they have not resulted in a decrease in bed use.

Self-management is a way for people to actively manage a condition; recognising the signs of crisis and knowing how to manage symptoms and other aspects of their life.  Interventions may aid self-management, but might be more effective when facilitated and motivated by someone else.  Peer support workers have had similar experiences to the people they are supporting, so are able to be a role model for recovery.

Who did we enrol in the study?

We recruited people who had been on the caseload of mental health crisis resolution teams, been discharged from the crisis resolution team in the previous month and had capacity to consent to taking part.  We did not recruit those who were deemed to be high risk to them or others, were discharged out of the area or who could not understand English.

What was the intervention?

This was a self-management workbook, which was adapted from other resources in an earlier CORE work package, which was facilitated by a peer support worker in up to 10 sessions.  In these sessions, peer support workers were encouraged to help participants complete the workbook and to reflect and discuss their recovery plans.  Peer support workers were also employed to provide supportive listening and instil hope of recovery, through sharing strategies to aid recovery learnt through their own recovery journey.

What was the comparison?

Participants in the control group were sent the workbook in the post, but did not have access to a peer support worker and were not given further guidance on how to use the workbook.  They could also access usual care.

What did we find?

We found that those randomised to the peer support worker group were less likely to be readmitted to acute care in the year after they enrolled in the study compared with those who were randomised to the workbook alone (29% versus 38% respectively).  Time to admission was also significantly longer in the intervention group, as was satisfaction with mental health care and self-rated recovery at 4 month follow-up.

What does this mean?

The rate of readmissions was lower than expected overall.  However, peer support workers have the potential to help reduce readmissions further in people who have had a mental health crisis, giving them the opportunity for a sustained recovery.  It also means that the burden on acute services will be less; potentially giving savings to the NHS.

Satisfaction with care related to all mental health services; even so as this was statistically significant at four month follow-up suggesting that participants liked having a peer support worker, and uptake of the peer support worker intervention was good.  If peer support workers after mental health crisis were more widely available, this may go some way to improving Trust satisfaction ratings.

 

Johnson S, Lamb D, Marston L, Osborn D, Mason O, Henderson C, Ambler G, Milton A, Davidson M, Christoforou M, Sullivan S, Hunter R, Hindle D, Paterson B,  Leverton M, Piotrowski J, Forsyth R, Mosse L, Goater N, Kelly K, Lean M, Pilling S, Morant N, Lloyd-Evans B (2018) Peer-supported self-management for people discharged from a mental health crisis team: a randomised controlled trial Lancet 392 409-428 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31470-3/fulltext

#OPAL2018: Identifying and addressing shared challenges in conducting health and social care research for older people

NathanDavies2 July 2018

In this post Rachael Frost from the Centre for Ageing and Population Studies discusses the fantastic achievement of being awarded a place on an international early career researcher workshop in Brazil.

I was recently lucky enough to be awarded a place on a Brazil-UK Researcher Links workshop: Identifying and addressing shared challenges in conducting health and social care research for older people (OPAL) in June 2018. Funded by the British Council, the Newton Fund and Sao Paolo Research Foundation (FAPESP), the workshop aimed to encourage collaboration among UK and Brazilian early career researchers and to develop joint research proposals to address some of the major challenges facing ageing research in both countries. As an early career researcher in the Centre for Ageing and Population Studies in PCPH, I was really excited about the opportunity to meet other early career researchers and share our experiences.

Brazil’s population is ageing rapidly, and in a much shorter time frame than many European countries. Whilst France had 150 years to adjust to a doubling in the proportion of the population aged over 60, Brazil has just 20 years. Dementia and frailty are on the rise in both Brazil and the UK. However, Brazil is approximately 35 times the size of the UK, and faces extra challenges in access to healthcare, particularly in rural areas (e.g. despite the size difference, the UK has almost ten times more GPs).

  Outside the Sao Paolo State University Faculdade de Medicina

The workshop was organised by Dr Kathryn Hinchliff-Smith, Dr Reena Devi and Associate Professors Adam Gordon and Alessandro Jacinto with teams from both the University of Nottingham and Sao Paolo State University. It brought together 13 UK early career researchers from a range of UK universities and 18 Brazilian early career researchers, in the small Brazilian city of Botucatu at the Sao Paulo State University School of Medicine. It was a long flight over (not helped by Adam telling us everything that went wrong with the plane the last time they flew out…), but well worth it when we got there!

As well as serving us copious amounts of tasty Brazilian food, the five day workshop included a talk each day from the workshop mentors. They discussed the context of ageing research in Brazil and the UK and the key challenges for each country. The early career researchers presented posters on current projects and future research interests, and took part in larger discussions of how the academic research context works in Brazil and the UK. We were also given a lunchtime tour of Botucatu’s hospital.

In addition to this, one of the main workshop aims was to develop international research ideas and grant proposals.

Our final day presentation

We were put in small groups, and spent a couple of days discussing our interests and ideas. It was sometimes a difficult balance trying to find a project that was both feasible and interesting to everyone in the group, however by the last day each group had formed clear plans for projects. We presented these ideas around dementia, frailty and palliative care to the rest of the group.

In addition to lots of hard work, we also made the most of fantastic opportunities to see round Botucatu. Although it was technically winter in Brazil, it was the same weather as an English summer. An enthusiastic group of us got up at 6am two days running to see the ‘base of the clouds’ (a beautiful sunrise view of miles of wilderness) and to have an early morning dip in a waterfall! We also managed to fit in evening piano concerts, coffee museum visits, acai berry ice cream and a fair few caiprinhas. Our Brazilian colleagues were fantastic and welcoming and showed us how to dance Brazilian style!

A pre-workshop waterfall visit

It was an amazing opportunity, and all our groups are planning to take our ideas forward with support from the workshop mentors. In addition to new proposals and collaborations, we also learnt a lot about each other’s countries (including a smattering of Portugese), and made new friends and colleagues in both Brazil and the UK. Obrigada, Brasil and hope to see you again soon!

 

A morning visit to the ‘base of the clouds’

Even modest amounts of activity from midlife are associated with significant health benefits

NathanDavies22 June 2018

In this post Daniel Aggio talks about his recent trip to the American Heart Association’s conference in New Orleans, and the exciting findings on the effects of physical activity and risk factors for cardiovascular disease. 

In March this year, I was fortunate enough to attend the annual American Heart Association’s conference on Epidemiology and Prevention (EPI Lifestyle) in New Orleans. The overarching goal of the conference is to promote development and application of translational and population science to prevent heart disease and stroke. The conference theme this year was health promotion: risk prediction to risk prevention, with a large focus on behavioural strategies to promote and sustain healthy lifestyles. This conference was highly recommended by my supervisors and it turned out to be a fantastic experience. There were some inspirational speakers from the field of physical activity, such as Professor Andrea LaCroix, who presented her work on American older women showing that light physical activity is associated with a reduced risk of cardiovascular events in later life. This was particularly encouraging given that a recent paper from the British Regional Heart Study (BRHS) mirrored these findings in older men.

On the first day of the conference, I was presenting in one of the moderated poster sessions and what a lively session it turned out to be. The poster I was presenting was from my PhD work utilising 20-years of physical activity data from the BRHS, a prospective cohort study of middle-aged men transitioning into old age. In this study I used group-based trajectory modelling, a form of latent class growth analysis, to plot trajectories of physical activity and examine their associations with a range of cardiovascular risk factors in old age. The take home message was that although sustained high levels of activity proved optimal, in fact sustaining more modest amounts of activity from midlife was also associated with significant health benefits. The session was well attended and I received some tips and advice from one of the first researchers to utilise group-based trajectory modelling in physical activity research, Dr Tracie Barnett. Since returning to UCL, I entered this poster into the Faculty poster competition in which I was awarded the runner up spot. It was amazing to see my work being recognised with so much other great research going on in the Faculty.

EPI Lifestyle also had a strong programme of events for early career researchers, including a three-minute thesis competition and a session on identifying your niche in academic research. I was also invited to participate in a round table discussion on forging International Collaboration, where I represented the BRHS. Representatives from cohort studies from around the world were in attendance along with early career researchers looking to find out more about these studies and opportunities for collaborations. This was a great opportunity to learn about other cohorts, many of which I hadn’t come across before, and also to network with some of the leading investigators of these studies. More information about these cohorts can be found here.

Overall, EPI Lifestyle was an amazing experience where I learned some great science, but the highlight for me was the networking opportunity. I made some valuable contacts that gave me some great advice and will no doubt be useful connections in my future career.

From Bed Blocking to Delayed Transfer of Care

NathanDavies20 December 2017

In this post Dr Catherine Jackman an ST6 inGeriatrics and General Medicine talks about the bed blocking we saw in the 1960s through to modern day ‘delayed transfer of care’ or becoming known once again as ‘bed blocking’. 

“NHS bed-blocking rises 42% in a year…”

“NHS ‘bed-blocking’ rises for sixth month in a row”

“’Bed-blocking’ patient left waiting three and a half years to be discharged…”

At a time when the NHS faces unprecedented change and challenges there is barely a day which passes when the media doesn’t comment on bed blocking (or as it is called today – Delayed Transfer of Care) and the huge number of older patients unnecessarily ‘stuck’ in hospital.

Delayed transfer of care (DToC) refers to the long term occupation of hospital beds, often by older patients, who are medically fit to be discharged but are unable to leave due to a shortage of available care options elsewhere.  The consequences of this are significant; there is a huge added cost to the NHS, beds are not appropriately utilised and many other patients may wait long hours in A&E for a free bed on the ward.  DToC patients suffer physically, in terms of hospital acquired infections, and psychologically.  They are at risk of becoming institutionalised and, in addition to this, staff morale takes a hit.

Evidence would suggest however that this has been a problem the NHS has had to deal with for many years.  Geriatric medicine has evolved over the past 60 years and the provision of care available to our older population has changed, but bed blocking and DToC continues.

Departmental reports from the geriatric medicine department in Stoke in the 1960s-1970s comment on the challenge of patient demand exceeding the facilities available to provide adequate care.  At that time there were, on average, 700 long stay beds for elderly patients in the Stoke area.  They functioned as the equivalent of today’s care homes but often without recreational or rehabilitative facilities.  Patients would also be admitted for “holiday respite” so that their family could have “a well-earned rest”.  Despite requesting relatives sign a “contract” to state they would take the patients back home this often did not happen.  One report is of an 87 year old widow who was admitted as a “holiday spell” and a form guaranteeing re-acceptance was signed by a son.  After admission the patient was found to be active, alert and continent.  After a month long admission the family refused to accept her home and involved a solicitor.  The patient then had to join a long waiting list for local authority provided accommodation instead.

Another patient report from the long stay facility is of a 76 year old woman whose son wrote “mother and I have not got on very well for years.  She has led a very useless life…Naturally, I feel very bitter about this…As you are aware the proper authorities will provide for her if you will only apply to them.  I cannot do anything more in this matter.”  This patient again joined the waiting list, “blocking” the hospital bed in the meantime.

The length of stay of these patients on the wards could often exceed 1 year.  And, as is the case today, many died or deteriorated whilst awaiting local authority funded welfare housing or placements.

Fast forward 20 years to 1986, a BMJ paper entitled “Bed blocking in Bromley” reported that more than 1 in 10 of all acute patients were classified as bed blockers – rising to 1 in 5 of medical patients.   The authors commented “bed blocking seems inevitable in wards attempting to cope with the steadily increasing proportion of elderly patients”.   They defined bed blocking as patients who remained in hospital for 4 weeks or longer, and in the opinion of the medical staff, no longer required the facilities provided there.  Reasons suggested in this study were similar to those of the earlier reports i.e. social and administrative problems as well as relatives refusing to have patients home.

After the 1980s there was a change away from long stay geriatric wards and care of our older population is now integrated into the acute hospital setting.  Additionally there has been far more emphasis on social care with social workers very much integrated into the hospital teams.  Since 2003 local authorities have been fined if they fail to organise care in a timely fashion.

The late 1990s and early 2000s was a golden period when the government tried to transfer the focus of care into the community and social care expanded.  However, following the financial crisis of 2008, in 2010 the government introduced a period of austerity and the rate support grant to local authorities has been reduced every year.  So, with cuts to their budget, there has been less social care spend despite an increasing demand exacerbated by steadily rising patient numbers and a declining number of beds.  Inevitably this has increased pressure on hospitals to provide the necessary care and resulted in the return of “bed blocking”.

A solution to the recurring problem of bed blocking, or DToC, has not been developed by any government as yet.  A proper integration of Health and Social Care would seem to be needed with joint funding.  This would involve a major upheaval/reorganisation which, as the King’s fund reports, is extremely difficult in a time of decreasing budgets.

Dr Catherine Jackman

catherine.jackman@nhs.net

The PCPH iBSc in Primary Health Care: 1997-present

NathanDavies22 June 2017

In this post Surinder Singh, Course Director for the iBSc in Primary Health Care gives us na update with some great feedback from past and present students.

We have just just “graduated” the twentieth cohort of students undertaking the Department’s integrated BSc in Primary Health Care (iBSc).  After their first two years at UCL  all medical students  undertake an iBSC year  which allows them to pursue an individual subject, of their choice, in considerable depth, with a strong emphasis on undertaking an extended research study.  This is a fundamental element of the medical school’s  mission to produce  “scientifically-literate” clinicians. (http://www.ucl.ac.uk/medicalschool/staff-students/course-information/year-3).

Ever since 1997 one of the iBSc options at UCL has been the iBSc in Primary Health Care.  This was the first primary care iBSc in the UK and each year we recruit a small but dynamic cohort of usually 10-14 students.

Over the last twenty years we have produced almost two hundred graduates, most of whom are now practising clinicians throughout the UK and abroad. The original Course Director was Melvyn Jones who subsequently handed over to current lead Surinder Singh.

The iBSc consists of six modules encompassing individual patient care, the consultation in primary care as well as health of the population and critical appraisal – now jointly taught with the iBSc in Paediatrics. The single largest module is Research* – led by Richard Meakin. This is a module which students find sometimes challenging, usually fascinating and always rewarding.   It is also the component where we are particularly keen to involve PCPH researchers and research students as project supervisors.  So please contact Surinder or Richard if you would like to get involved or have a small project in which you think a bright and well-motivated student could contribute in return for your supervision.

A short video about the iBSc and a list of all projects and abstracts/scientific papers are on the iBSc website.

Two recent graduates have kindly sent us  the following comments about their experiences of the iBSc in Primary Health Care for this blog:

Student Rajit  Randhawa writes:

“As far as I am aware primary healthcare is only amongst a few iBScs to offer patient contact – one day a week throughout the year.  Not only does this help tie in the theoretical learning about consultation models and patient-belief systems, it most definitely prepares us for the 4th year clinics and in my opinion, is a truer placement than the 5th year GP placement because we actually see continuity of care over a prolonged period.  In my time at my medical practice I clerked and examined many patients, performed basic procedures such as flu jabs, and even had the opportunity to write up an inquest into a patient’s death in addition to doing more routine tasks such as home and hospital visits”

 And of the teaching during the year:

“I cannot think of a single session where I thought the teaching was overbearing or too complex. Tutorials can be up to three hours but it’s not as bad as that since the format lends itself to promoting healthy and productive discussion between different groups of students.  As someone who was often happy to sit silently I now appreciate being driven out of my comfort zone, and it has helped to develop my confidence speaking to larger groups”

Another graduate of the course, Joht Chanda– now a junior doctor wrote:

 “I am currently finishing my Foundation Year 1 in the West Midlands. During medical school at UCL I was fortunate to get onto the iBSc in primary care and population health after my pre-clinical years.  I wasn’t sure what to expect before starting the course, however the lessons I went onto learn, were extremely positive in shaping where my career is currently going.

 The iBSc was the first opportunity I ever had to try taking part in research. Academia was not something I had ever considered before, as in my head I thought it usually consisted of lab work and being told what to do (two things I can’t stand!).

 However, in comparison to the other courses available, this iBSc was one of few to give you an opportunity to run a research project from start to finish, even applying for our own ethics (I can say happily now, but not so much back then!).  Although seemingly daunting at the time, the task of designing my own project was possibly one of the most useful I was able to complete during medical school.  It meant that in the proceeding clinical years, I had a solid grounding in research methods and was able to start taking on work myself that others in my year group wouldn’t have the knowledge of where to start.  

 Being self-sufficient meant I was able to strengthen my application for foundation years without having to rely on others for opportunities.  Instead this self-sufficiency taught in the iBSc meant I was the person responsible for creating the opportunities. The iBSc supervisory team were extremely supportive and even helped me publish my project and present it at conferences; these were great stepping stones for the future as most career paths usually prefer some level of academic engagement.

 I cannot explain quite how useful doing the course was for me and how thankful I am to have got on it, thinking back”.

Joht wrote a paper with Richard Meakin for BMJ Open and Rajit has produced a poster for a conference in 2017.

 

PLEASE DO GET IN TOUCH IF YOU WOULD LIKE TO GET INVOLVED

We are currently recruiting projects supervisors for the new cohort of eleven  iBSc students starting in September 2017.  If you are a PhD student/post doc and would like to get involved  please do contact  Surinder Singh or Richard Meakin

Nathan Davies, winner of this year’s RCGP/SAPC Yvonne Carter Award for outstanding new researcher

NathanDavies24 May 2017

This years winner of the Yvonne Carter Award is Nathan Davies.

Each year the RCGP and the SocieNathan Davies Research Fellow PCPH (2)ty for Academic Primary Care (SAPC) award the Yvonne Carter Award for Outstanding New Researcher, and each year the competition gets harder. This year panel members from the RCGP Scientific Foundation Board (SFB) and SAPC reviewed several high-quality applications from early career researchers.

Dr Nathan Davies, a Research Fellow at UCL, impressed all the panel members with the number of grants he has secured and projects he has collaborated on in the three years since completing his PhD. Here Nathan outlines his plans for the award, and talks about his career journey.

What is your main area of interest, and how did that develop?

My research currently focuses on end of life care for people with dementia and how we can improve the experience of care not only for patients, but also for families and others affected by dementia. I have a particular interest in making decisions at the end of life and supporting practitioners to make decisions with patients and their families; we know this is an area that practitioners find challenging and I hope that my research will support GPs with this.

My background is in Psychology. I worked in memory clinics and I noticed a pattern whereby we would see patients with mild to moderate stages of dementia, but they then fell off our radar. This got me thinking about what was happening in the wider context. There was also little support for those with later stages of dementia, which surprised me. Through my early work, I realised that most  guidelines and research for example was very practitioner oriented with little input from family carers, who we know provide most support day to day and are experts through experience.

What does your research involve?

My PhD was a large piece of qualitative research; I carried out in depth interviews with 47 family carers. I wanted to find out what their experience of end of life care was, what do they see and what are their experiences? I realised that their priorities aren’t always the medical but usually centre around the psychosocial importance of end of life care – being treated with respect and dignity.

My post-doctoral work has focussed on two areas: 1) supporting practitioners make decision through the development of rules-of-thumb. These have been implemented in NHS sites and the Alzheimer’s Society have incorporated them into their end of life training programme; 2) supporting family carers at home with the development of an online support tool.

How will you use this award?

This award will allow me to expand my networks with lower income countries, and I’m specifically interested in working with Sri Lanka.

Sri Lanka has an increasing ageing population with the highest proportion of older adults in South Asia. This award will allow me to travel to Sri Lanka to carry out workshops with GPs and the Ministry of Health to provide education, awareness and an understanding of dementia and how they can support family carers. I will also hold workshops with family carers to not only provide them with support, but also to learn more about their approach to caring for people with dementia.

Based on your experience, what advice do you have for people who are interested in working in the research field?

You can’t underestimate the importance of networking in research. This means ensuring you are talking to people that do similar work, but also networking with those who have different research interests not necessarily in a directly related field. There is so much we can learn from each other.

Academia is changing and social media is becoming a huge part of what it means to be involved with research. I use Twitter to keep up to date with new research and key topics in the field of healthcare, but also to talk about the work that I’m doing. It’s also useful to blog about new research or publications to disseminate findings. You can’t rely on people reading academic papers anymore!

Make sure to get involved in lots of different events and networks across not just your research group or department, but also the wider institute and organisations such as the SAPC or RCGP.

Lastly, I would say to not be afraid to keep trying when you’re not successful – whether it’s a grant application or an unsuccessful publication, don’t get disheartened and go for it again!

This post was originally published on the RCGP website.  

The potentials of international collaborations

NathanDavies9 May 2017

In this post Nathan Davies talks about his recent oversees visit and the importance of developing international collaborations. 

Working as a researcher in academia, one of the great benefits we have is the ability to work with others from across the globe and travel to visit them; sharing our ideas, results and enthusiasm for the work that we do. And this is exactly what I have done recently in Hong Kong and Australia. But importantly it is not just a benefit but I think a vital part of academia, learning from other leading academics and health care systems.

In 2011 I started working on a European Commission funded study whic

Learning about Traditional Chinese Medicine

Learning about Traditional Chinese Medicine

h had a whole host of leading academics in both dementia and palliative care not just from Europe but even from Australia. It was at this point I met Prof Wendy Moyle from Griffith University, Brisbane, Australia who invited me to visit her and the team at Griffith. I did so back in 2015 and have just returned from my second visit.

On the way to Australia I made a quick but exciting pit-stop at Hong Kong Polytechnic University, where I was hosted by Prof Wai Tong Chien at the School of Nursing. In addition to presenting the work I have been doing as part of my NIHR School of Primary Care Research Fellowship, I met with members of the team to understand how cultural variations affect the provision of end of life care, for example a hot topic was the use of feeding tubes in people with dementia. But, it was also fantastic to see how Hong Kong uses the latest technology to train their new generation of aged care nurses, with specifically designed teaching labs.

Following Hong Kong I was in Australia for just over four weeks – although, I must admit it wasn’t all work and I did take a bit of time to have a holiday out there too. For the first part of the trip I was in Sydney and I met with various academics from three different universities; University of New South Wales, University of Sydney, and University of Technology Sydney. I presented some of the exciting work that we have been doing here in the UK, including my work on developing an online support tool for family carers of people with dementia, as part of my SPCR Fellowship. In Sydney I was particularly keen to hear about the digital interventions and trials which are currently underway which focus on supporting families and people with dementia. At UNSW I met with Prof Henry Brodaty and Dr Megan Heffernan who went through their Maintain Your Brain project which is about developing a website for use by teaching people how to manage modifiable risk factors for dementia. We were able to have a lengthy discussion regarding the design of websites but also the challenges of eHeND Sydney UNSWalth interventions in academic research, learning some valuable lessons for my own eHealth research. I was also able to meet with Associate Prof Lee-Fay Low who discussed her trial of CareToons which is an online program on management of behaviour changes for carers of people with dementia. These were great learning opportunities to bring back to my own work here in the UK.

Moving up the coast to Brisbane, I spent a week with Prof Moyle and her team meeting and learning a lot from different academics and clinical staff, including Prof Elizabeth Beattie, the Director for the Dementia Collaborative Research Centre: Carers and Consumers. I also visited a long term care facility Jeta Gardens. This was a great opportunity to learn not just about aged care in Australia but also to learn about the architectural design of aged care facilities.

Jeta Gardens tour

Jeta Gardens tour

Prof Moyle has a large group of PhD students from across Australia and the rest of the world. I was asked to provide a qualitative methods workshop to get the students thinking about what qualitative research is and how it can work with and alongside quantitative research. This was a great chance to learn about the PhD students’ work and to understand how they could see qualitative methods working within their work, much of which was clinical trials.

I can definitely say this was a fantastic opportunity to have early on in my research career and I left having developed some fantastic connections and learnt a lot not only about research methods and topics, but also about how aged care works in different countries. As part of this trip I am also now supervising a new PhD student studying at Griffith University, conducting a qualitative study exploring end of life care for older adults in Ghana. I will remain in contact with Prof Moyle who is now also a mentor in my future work and new fellowship.

I 100% encourage everyone especially early career researchers to think about who they want to work with outside of the department, not just nationally but also internationally, and don’t be afraid to go for it!

On the 21st July Dr Lee-Fay Low will be visiting us from Sydney giving a talk for our seminar series about her work on CareToons and several other projects she has been involved in, please do come along.

The Lancet: Offering a ‘stop smoking’ taster session and personalised disease risk doubles likelihood smokers will seek help to quit

NathanDavies25 January 2017

Dr Hazel Gilbert and her team have today had their start2quit trial findings published in The Lancet. Read the official press release from The Lancet below.

s2q

Smokers underestimate their personal risk of illness, and a key aim of the study was to try and persuade them that these risks are personally relevant.

Offering smokers a taster session at an NHS Stop Smoking Service and explaining their personal risk of developing smoking-related diseases doubles their likelihood of attending a stop smoking course, according to a study in The Lancet.

Smoking is the leading cause of preventable ill health worldwide. Although smoking rates in England have halved since 1974, this decrease has slowed since 2007, and the total cost for the National Health Service to treat smoking-related disease was estimated at £5.2 billion in 2005-06.

NHS Stop Smoking Services combine specialist support with prescribed medication, and are an effective way of helping people to stop smoking.  However, attendance is low and only around one in 20 (less than 5%) smokers use the service each year.

In the trial, 4384 smokers from 18 service areas across England were either given a routine referral letter (1748 people) or a new personalised letter explaining their individual risk of smoking-related diseases and offering them a stop smoking taster session (2636 people).

The personalised letter included the person’s individual risk of serious illness if they continued to smoke, rating them as being at high, very high or extremely high risk compared to people who used to or never smoked. It also included information about how much their risk would reduce if they quit smoking immediately. The calculations were based on information from the person’s medical records. For example:

Based on your smoking habits and your personal health, your current risk of developing a serious illness and suffering an early death is very high compared to a non-smoker or ex-smoker of your  age… Even by smoking 12 cigarettes per day you are seriously increasing your risk of developing one of these major diseases and dying sooner than you need toThe good news is that if you quit now, at 45, you can halve your additional risk of contracting these diseases, or of suffering any other conditions such as a stroke and osteoporosis…”

The trial found that 17% (458) of those who received the personalised letter attended the first session of a Stop Smoking Service course within six months of receiving the letter, compared with 9% (158) of those who had the routine referral letter – meaning the personalised letter doubled the likelihood that a person would attend. It also doubled the likelihood of people completing the full six-week course (15% (382) vs 7% (123)).

Six months after receiving the letter, those who had the personalised letter were more than 1.5 times more likely to have gone without a cigarette for a week (9% compared with 5.5% [2]). Those who didn’t attend the Stop Smoking Service were least likely to have quit for a week (4.4% of those who received the personalised letter and 4.9% of those who had the routine letter).

Of those who took up the offer and attended the taster session, and also subsequently attended the Stop Smoking Service, 28.7% achieved 7-day abstinence. smoking jan 17

“Smokers underestimate their own personal risk of illness, so a key aim in motivating them to try to quit is to persuade them that these risks are personally relevant. Individual risk information can also arouse fear or concern, which might prompt them to quit, particularly when combined with a reassuring message that doing so would be effective and that help is available,” said lead author Dr Hazel Gilbert, University College Medical School, UK. “The combination of hard-hitting “why quit” messages about the consequences of tobacco use, and supportive and positive “how to quit” messages, emphasising quitting resources, has been shown to be effective in some mass media campaigns. In our study, we found that this combination of personalised risk and easy access to a session doubled smokers’ likelihood of attending and increased their chances of quitting.” [1]

Overall smokers found the taster sessions helpful and interesting. Two-thirds of participants (66%) found the letter useful and very few found it antagonistic, depressing or anxiety-inducing, suggesting that using risk information while offering support was an appropriate way to target smokers.

The researchers estimate that the intervention would be a cost-effective use of NHS resources. While the intervention is more costly than the usual treatment in the short term, the authors say that it is likely to be cost-effective in the longer-term because of health-care cost savings and health benefits attributable to the reduced risk of smoking-related diseases.

Limitations of the study are that only 18 of 151 Stop Smoking Services in England participated, and that the proportion of potentially eligible smokers recruited was low. The average age of smokers involved in the trial was 49 years-old meaning the results may not be representative of a younger age group.  More research is needed to confirm how this intervention would apply in practice.

Writing in a linked Comment, Dr K Michael Cummings, Medical University of South Carolina, USA, said: “Most people who have smoked for any significant length of time would like to stop smoking. Findings from prospective studies examining the natural history of efforts to stop smoking show that smokers often make frequent efforts to stop smoking or reduce their consumption, with little long-term success… Low attendance at Stop Smoking Services is a concern because evidence shows that these services are not only a highly cost-effective medical intervention producing higher quit rates than other approaches, but are also effective in reaching smokers from disadvantaged communities… Government authorities should resist any cost-cutting suggestions to decrease support for the Stop Smoking Services on the basis of the obvious and well documented benefits achieved when smokers are enrolled in these services.”

 

NOTES TO EDITORS

The study was funded by the National Institutes of Health Research Health Technology Assessment. It was conducted by scientists from UCL, the University of Cambridge, Smokefree Camden, and the University of York.

[1] Quote direct from author and cannot be found in the text of the Article.

[2] 9% of all people who received the personalised letter and invitation to a taster session (236 of 2636 people; ie. Including people who did not attend the services) and 5.5% (97 of 1748 people) of all people who received the routine referral letter.

 For interviews with author, Dr Hazel Gilbert, University College Medical School, Royal Free Campus, UK, please contact: E) hazel.gilbert@ucl.ac.uk T) +44 (0) 1635 203484 / +44 (0) 788 4121630

 For interviews with Comment author, Dr K Michael Cummings, Medical University of South Carolina, USA, please contact E) cummingk@musc.edu / carpente@musc.edu T) +1 843 876 2429 / +1 843 876 2436

Dementia the leading cause of death in England and Wales?? What is really going on?

NathanDavies29 November 2016

NDThis month Nathan Davies talks for the NIHR School for Primary Care Research about the news that dementia is now the leading cause fo death in England and Wales, and explains about some of the factors which may be underlying this revelation.

Last week we saw the Office for National Statistics announce that Alzheimer’s Disease and other dementias have become the leading cause of death in England and Wales. It has replaced heart disease, with 61,686 out of 529,655 recorded deaths last year in England and Wales. Now this sounds all very alarming, but actually we know from recent studies that the incidence of dementia is falling. However, our population is ageing and therefore the prevalence of dementia is increasing. All a bit muddy.

But, why are we seeing dementia now as the leading cause of death? There are many reasons as to why this number has increased. We have seen an improvement in the diagnosis of dementia across the country, including the inclusion of dementia diagnosis in Local Enhanced Services in Primary Care. In addition to this doctors are now much more likely to record dementia as an underlying cause of death on death certificates and not simply record pneumonia for example.

Regardless of all the factors which lie behind this news, dementia is one of the biggest health concerns facing older people, and the health and social care systems. There is no cure or disease modifying treatment for dementia as yet and only this week we saw that a drug (solanezumab) which sounded promising last year, has been reported as unsuccessful in delaying or slowing down the progression of Alzheimer’s Disease.

With no known cure it is vital that not only does research into treatment, cure and prevention continue, but also that care based research continues. As a School the NIHR School for Primary Care Research currently funds many dementia care pieces of research, and I am fortunate enough to receive some of this funding.

My work at UCL focusses on end of life care for people with dementia. As part of this work I  am exploring the support and challenges that family carers of people with dementia face at the end of life. Families provide the majority of support to people with dementia and it is vital that they are supported too. Our study CADRE is developing a website to provide support for family carers when caring for someone with dementia at the end of life. We are still in the development stages of our study and building our prototype website, but keep an eye out as we will soon report what we think a website needs to include and how this should look! Initial suggestions include elements of networking and social interaction, including a function to identify other carers in the local area.

Ct_7Vp4WEAARbH4Our other study ‘After the Liverpool Care Pathway: What next for people with dementia?’, which has recently come to an end has developed a series of rules-of-thumb for practitioners providing end-of-life care for people with dementia. Our rules-of-thumb cover the core and most difficult decisions facing a practitioner at the end-of-life: eating/swallowing difficulties, providing routine care, reviewing treatment and interventions, and agitation and restlessness. The rules-of-thumb provide a practical toolkit for making decisions and make the implicit knowledge which has been built up over a number of years explicit. Potentially, this is a great method for training junior staff and those less experienced who work with people with dementia at the end-of-life, but it also provides practical and on-the-job assistance. The toolkit has been taken up by the Alzheimer’s Society who are currently looking at ways to implement it in their training packages.

Although the prevalence of dementia is increasing, and it is now the leading cause of death, it is important to realise, as a research community particularly within primary care and the School, that we are conducting timely studies in an effort to help health and social care practitioners, carers and those affected by dementia.

‘Doctors as Patients’: Exploring the barriers and facilitators to help seeking for mental health problems by GPs and improving access to support

NathanDavies16 November 2016

nov 2016Marta Buszewicz discusses the primary care mental health research project, exploring the mental health of general practitioners, which  is an NIHR School of Primary Care (SPCR) funded study which is still underway.

There has been a great deal written in the press about the considerable and increasing work pressures which general practitioners (GPs) in the UK are currently under, along with  significant financial constraints and difficulties recruiting sufficient new GPs to replace those who are leaving or retiring. Something which has been explored less are the emotional and mental health difficulties experienced by many GPs, which they are often reluctant to disclose or may feel unable to seek appropriate help for. There is evidence that doctors, including GPs, are more likely than the general population to experience mental health symptoms such as anxiety, depression, stress and burnout.

This qualitative study involved 47 interviews with a wide range of GPs recruited from a variety of locations and including the following groups: those currently living with anxiety, depression, stress and/or burnout; those returning to work following treatment for such conditions; those off sick or retired early due to mental health problems and those who have not personally experienced mental health problems but were interested in the project. The study proved quite easy to recruit to, with so many GPs approaching us wanting to take part that we had to turn quite a few away after interviewing more than the initial recruitment target of 40 participants. I think this indicates how many practitioners are likely to be suffering in silence, and who welcomed the opportunity to speak in confidence to an empathic researcher about the problems which they were experiencing.

The research team were struck by the very high levels of stress, depression and anxiety experienced by many of those interviewed. It was also clear that many felt quite isolated, and that it was difficult for participants to acknowledge their difficulties within the practices they work in for fear of burdening the other doctors working there. It is also very difficult for many GPs to seek professional help for their psychological problems, as they often have concerns about confidentiality if the GP they are registered with is someone who they know locally in a professional context. Many GPs are reluctant to take time off sick because of the impact this is likely to have on their colleagues’ workload, as well as difficulty getting appropriately qualified locums in the current climate.wordcloud

We have now finished interviewing all the participants and the analysis is underway. Preliminary results were outlined in a recent British Journal of General Practice (BJGP) editorial. Which you can download here.

An innovative component of our research project is that it has also informed two performances in November at an Arts Festival in Bristol . Which we have discussed in a recent BJGP blog.

In writing up the final results from this project and describing and discussing the various issues involved, we aim to highlight the emotional component of most GPs’ workload and encourage the primary care community to openly recognise this and be more supportive of each other. We also plan to make recommendations which can inform the provision of appropriate services for distressed GPs and which they can access without necessarily going through their GP if confidentiality is an issue.

I will give further details when the results of the study have been published.  It is being led from Bristol – more details of the project and the study team are available on the Bristol website.

This blog describes independent research funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR). The views expressed are those of the author(s) and not necessarily those of the NIHR, the NHS or the Department of Health.